UC-NRLF 


B   M    blT   3fiD 


LECTURES 


ON 


Military  Sanitation  and  Manage* 
ment  of  the  Sanitary  Service 


— ^ 

ARMY  SERVICE  SCHOOLS 


SPECIAL  REPRINT  FOR  OFFICERS'  TRAINING  CAMPS 


GOVERNMENT  PRINTING  OFHCE 

WASHINGTON 

1917 


LECTURES 


ON 


Military  Sanitation  and  Manage- 
ment of  the  Sanitary  Service 


U  .  ^       ARMY  SERVICE  SCHOOLS 


SPECIAL  REPRINT  FOR  OFFICERS'  TRAINING  CAMPS 


GOVERNMENT  PRINTING  OFHCE 

WASHINGTON 

1917 


u^^ 


?'0L06Y 


CONTENTS, 


Lecture  I.  [Military  hygiene 5 

II.  Militarj'  hygiene 23 

III.  Military  hygiene 37 

IV.  The  sanitary  service  of  the  march  in  campaign 56 

V.  Sanitary  service  of  the  camp 69 

VI.  Sanitaiy  service  in  combat 84 

VII.  Sanitary  service  in  combat,  station  for  slightly  -vrounded 97 

3 


3631G2 


LECTUEE  I. 


MILITARY  HYGIENE. 

Hygiene  is  a  science  which  deals  with  the  preservation  of  the  health. 
Its  existence  depends  on  past  scientific  discoveries.  Sanitation  is 
the  method  which  is  adopted  to  carry  out  the  principles  of  hygiene. 
Stinitary  methods  may  differ,  but  yet  be  effective,  m  the  same  way 
that  many  problems  m  geometry  may  be  solved  by  different  methods. 
Sanitation,  therefore,  is  the  application  of  scientific  discoveries  to 
prevent  disease.  "IMihtary  sanitation''  should  be  used  instead  of  the 
words  ''military  hygiene  "'as  hygiene  covers  all  principles  to  insure 
health  and  the  application  of  these  principles  in  the  mihtary  service 
is  the  method  of  deahng  with  men  livmg  under  conditions  somewhat 
foreign  to  those  that  civihzation  has  caused  to  exist. 

A  medical  officer  has  many  duties  to  perform.  There  is  hardly 
anythhig  pertauiuig  to  a  soldier  that  he  is  not  in  some  way  required 
to  make  recommendations  or  act  on  his  own  initiative,  but  his  prin- 
cipal duty  in  time  of  war  is  to  initiate  the  proper  sanitary  measures, 
and  without  your  intelUgent  help  as  officers  he  will  not  be  entirely 
successful.  The  greatest  achievements  toward  mihtary  efficiency 
in  our  Army  so  far  have  been  accomphshed  by  the  Medical  Corps  by 
scientific  discoveries  and  theh*  appHcation,  and  the  officer  who  is 
now  in  command  of  men,  and  who  does  not  give  this  subject  the 
proper  attention  must  necessarily  be  a  failure. 

In  all  the  wars  that  history  records  (possibly  with  the  exceptions 
of  the  Russo-Japanese  War,  and  the  present  disturbance  abroad) 
much  more  disabihty  and  many  more  deaths  have  resulted  from 
disease  than  from  wounds.  The  failures  of  armies  on  account  of 
preventable  diseases  are  not  few.  Arnold  in  1775  was  unsuccessful 
because  smallpox  and  dysentery  incapacitated  the  command.  In 
1802,  15,000  of  Napoleon's  aimy  perished  in  Santo  Domingo  of 
yellow  fever  and  other  preventable  tropical  diseases.  The  British 
in  the  Crimea  lost  twenty-five  times  more  men  from  disease  than  from 
womids.  In  the  Spanish- American  War  there  were  seven  times  more 
deaths  from  sickness  than  was  caused  by  the  enemy.  During  the 
Balkan  wars  cholera  in  the  Bulgarian  Army  and  typhus  fever  in  Ser- 
bia during  the  present  war  greatly  influenced  the  results  of  the  attack 
in  the  former,  and  the  defense  of  the  latter. 

5 


8  MILITARY    SANITATION    AND    SANITARY    SERYICE. 

Height,  weight,  chest. — In  the  absence  of  actual  diseased  condi- 
tions the  physical  attributes  which  chiefly  determine  the  acceptance 
or  rejection  of  an  applicant  for  enlistment  are  the  height,  the  weight, 
and  the  chest  measurements.  In  normal  individuals  these  bear  a 
fairly  definite  relation  to  each  other,  which  relation  is  set  down  in 
official  tables.  Men  whose  chest  circumference,  at  rest,  is  below  32 
inches  should  not  be  accepted,  for  such  a  chest  has  not  sufficient  air 
capacity.  The  present  minimum  of  height  is  5  feet  4  inches.  The 
question  of  height  is  not  quite  so  important  now  as  in  the  days  of 
shock  action.  Other  things  being  relatively  equal,  the  smaller  man 
is  generally  quicker  in  his  movements  and  has  more  endurance.  In 
these  days  of  specialism  we  might  well  accept  vigorous  men  who  are 
a  little  shorter  than  the  present  requirement  for  special  service,  thus 
releasing  others  of  standard  height  for  the  fighting  line.  With  respect 
to  weight,  men  of  the  'Viry"  type  may  be  accepted  when  they  are 
but  a  few  pounds  under  the  standard,  but  the  mistake  must  not  be 
made  of  confusing  these  with  cases  of  defective  or  arrested  develop- 
ment. Li  these  latter,  deficiency  in  weight,  pallor,  flabby  muscles, 
a  flat  chest,  sloping  shoulders,  and  generally  poor  physique  denote  a 
feeble  constitution. 

Records. — It  is  essential,  for  the  protection  of  the  Government, 
that  careful  records  be  made  (a)  of  aU  departures  from  the  normal, 
including  minor  ones  which  are  not  considered  disqualifying,  and  (b) 
of  means  of  identification.  The  fii"st  is  needed  as  a  defense  agamst 
unjust  claims  for  pension.  The  second  leads  to  the  detection  of  crim- 
inals, deserters,  bomity  jumpers,  and  dishonorably  discharged  men 
who  enlist  fraudulently. 

Depots. — Owing  to  the  widespread  derivation  of  recruits,  depots 
for  their  coUection  and  training  are  frequently  afflicted  with  one  or 
more  kinds  of  contagious  diseases,  brought  by  some  who  have  con- 
tracted them  elsewhere.  It  has  sometimes  happened  that  measles, 
mumps,  or  some  other  commmiicable  disease  has  developed  in  parties 
of  men  sent  from  depots  during  the  trip  or  shortly  after  arrival  at 
their  destination.  Ai'my  posts  have  thus  been  frequently  infected, 
whfle  the  health  of  the  traveling  public  has  been  endangered.  If, 
therefore,  such  a  disease  exists  at  depots,  the  men  who  have  been 
exposed  to  contagion  should  be  isolated,  in  separate  squads,  until  the 
period  of  incubation  of  that  particular  disease  is  past  If  a  case 
develops  in  any  one  squad,  none  but  members  of  that  squad  have 
been  exposed  to  it  and  the  othei"s  may  safely  be  forwarded.  A  similar 
procedure  is  advisable  in  camps. 

Vaccination. — One  of  the  first  requirements  after  the  enlistment 
of  a  man  is  to  have  him  vaccinated  against  smallpox  and  typhoid 
fever.  This  is  a  very  important  procedure,  lookmg  to  his  future 
health  and  that  of  the  Ai-my. 


MILITARY    HYGIENE.  9 

PERSONAL  HYGIENE. 

Nature  and  importance. — Personal  hygiene  means  preserva- 
tion of  health  by  attention  to  the  care  of  the  body.  It  is  obvious 
that  such  care  is  essential  to  keep  the  physical  character  of  the  soldier 
up  to  the  proper  standard.  Napoleon  is  reported  to  have  said:  "The 
most  important  quality  of  the  soldier  is  his  ability  to  support  fatigue 
and  privation;  physical  courage  is  only  second."  Whether  or  not 
this  be  true,  it  must  be  apparent  to  any  thinking  individual  that 
personal  merits,  includmg  courage,  are  of  little  avail  to  the  military 
man  if  he  has  not  bodily  vigor. 

Formation  of  correct  habits. — Military  efficiency  in  an  indi- 
vidual, then,  rests  upon  certain  considerations,  chief  among  which 
are  health,  strength,  and  activity.  To  secure  and  keep  these  qualities 
it  is  essential  for  every  man  to  form  such  habits  as  experience  has 
shown  to  be  necessary.  These  habits  are:  Personal  cleanliness;  regu- 
lation of  diet;  avoidance  of  excesses  (particularly  in  eating,  drinking, 
and  sexual  matters);  wear^g  suitable  clothing;  keepmg  the  bodUy 
processes  at  work  (kidneys,  bowels,  skin) ;  taking  sufficient  exercise, 
preferably  in  the  open  air;  devoting  a  proper  part  of  each  day  to  rest 
of  the  body  and  mind,  with  recreation  for  the  latter;  maintaining  the 
surroundings  in  which  one  fives  in  a  cleanly  state. 

Personal  cleanliness. — The  maintenance  of  personal  cleanli- 
ness is  even  more  necessary  in  the  military  service  than  in  civil  fife. 
Tliis  is  due  in  part  to  the  violent  exercises  requh'ed  of  the  soldier, 
with  the  resultant  dirt  and  sweat,  but  especially  because  so  many 
five  together  within  a  small  space. 

Baths  and  bathing. — The  most  important  requirement  to  insure 
cleanliness  is  bathing.  Baths  are  necessary  partly  to  rid  the  skin  of 
external  impurities,  but  chiefly  to  keep  open  the  pores,  which  are  the 
mouths  of  the  sweat  glands,  whose  product  carries  away  large  amounts 
of  waste  and  poisonous  matters  from  the  blood.  Each  man  has  a 
preference  for  a  certain  temperature  of  the  water  in  which  he  takes 
his  bath;  this  varies  from  freezmg  to  hot,  A  cold  bath  is  stimulating 
and  is  to  be  preferred  for  a  vigorous  man,  provided  he  "reacts"  well 
and  feels  a  glow  on  emerging  from  the  bath  and  rubbing  down. 
The  cold  bath  is  not  suited  to  elderly  men  nor  to  those  whose  circula- 
tion is  poor.  The  proper  time  for  cold  bathing  is  on  arising  in  the 
mornmg,  not  at  bedtime,  as  sometimes  indidged  m. 

It  is  worthy  of  mention  that  the  practice  of  cold  bathing  often 
breaks  up  the  habit  of  "taking  cold,"  to  which  certain  people  are 
liable. 

Hot  and  warm  baths  are  soothing  and  best  remove  surface  dirt; 
they  are  grateful  means  of  reducing  muscular  soreness  after  exertion, 
and  will  often  induce  sleep  in  a  restless,  wakeful  person. 


10  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

The  most  desirable  means  of  batliiiig  is  perhaps  in  a  tub  in  which 
he  whole  body  may  be  immersed ;  in  default  of  this,  and  particularly 
in  barracks,  the  shower  bath  is  very  satisfactory.  If  means  for  com- 
plete bathing  are  not  available,  careful  attention  should,  in  any  event 
be  given  to  the  daily  cleansing  of  the  armpits,  crotch  and  feet,  as  well 
as  the  hands  and  face.  The  hands  should  be  washed  after  defeca- 
tion and  urination,  lest  they  convey  disease  germs.  The  nails  must 
be  well  kept  and  clean.  On  the  march,  if  no  water  is  available, 
a  vigorous  "dry  rub"  with  a  coarse  towel  will  be  found  refreshing  as 
well  as  cleansing.  The  scalp  should  be  washed  at  least  once  or  twice 
a  month  and  should  be  stimulated  daily  by  brisk  rubbing  with  a 
brush  or  the  fingers. 

Care  of  the  teeth. — Every  man  should  own  a  good  toothbrush 
and  use  it  with  a  tooth  powder  or  mild  antiseptic  (listerine,  for  in- 
stance) at  least  twice  a  day.  If  no  tooth  powder  is  available,  wood 
ashes  or  wood  charcoal  make  efficient  substitutes. 

Clothing. — Since  clothing  (especially  the  underwear)  when  soiled 
with  sweat  and  dust  is  irritating  to  the  skin  and  gives  off  disagree- 
able odors,  it  is  necessary  to  keep  this  as  clean  as  the  body.  The 
soldier  can  not  keep  his  person  clean  if  his  garments  are  filthy.  There- 
fore, whenever  possible,  the  soiled  clothing  should  be  washed  (and 
with  soap  if  it  can  be  had).  If  the  articles  are  of  wool,  they  should  be 
washed  in  cold  water  and  dried  without  wringing.  On  the  march 
a  man  should  have  two  suits  of  underclothes  to  wear  on  alternate 
days,  thus  insuring  cleanhness  if  the  garments  are  regularly  washed. 
If,  at  the  end  of  the  day's  march,  water  is  not  available  for  this  pur- 
pose, the  gamients  should  be  dried,  then  beaten  or  well  rubbed,  and 
hung  up  in  the  air. 

Skin  diseases. — In  campaign,  skin  diseases  due  to  animal  para- 
sites, especially  lice  and  the  itch  mite,  usually  make  their  appearance 
and  cause  much  disgust  and  discomfort.  They  must  be  watched  for 
and  report  of  their  presence  promptly  made  to  the  medical  officer. 

Diet. — In  the  soldier's  life  the  diet  is,  of  course,  regulated  as  far 
as  possible  by  the  authorities  who  design  and  issue  the  ration  and 
train  the  cooks  by  whom  the  articles  composing  it  are  prepared.  In 
campaign,  mifitary  considerations  may  necessitate  cutting  away  from 
the  base  of  supply,  so  that  soldiers  are  obliged  to  five  on  the  resom'ces 
of  the  country  in  which  they  are  operating  or  even  to  subsist  for  a 
few  days  upon  the  emergency  ration.  Every  soldier  should  bo  re- 
quired to  learn  how  to  prepare  his  individual  field  ration,  since  the 
necessity  for  this  frequently  occurs  in  field  service. 

The  character  of  the  food  taken  should  vary  in  accordance  with 
the  conditions  of  bodily  vigor,  occupation,  chmate,  and  food  values. 
A  vigorous  man,  doing  heavy  work,  requires  more  nourislunent  than 
one  of  delicate  physique  following  a  sedentary  pursuit.     Climate  is 


MILITARY   HYGIENE.  11 

an  important  factor.  Mon  serving  in  Alaska  need  a  large  amount  of 
fats  to  serve  as  fuel  in  maintenance  of  the  temperature  balance. 
Those  on  duty  in  the  PhiUppines  require  a  large  proportion  of 
sugars  and  starches. 

Dietary  don'ts. — A  few  general  dietary  principles  follow,  which 
may  perhaps  best  be  expressed  in  the  form  of  prohibitions : 

Don't  eat  hurriedly. 

Don't  swallow  a  morsel  till  it  is  thoroughly  broken  up  and  mixed 
with  the  saliva  by  chewing. 

Don't  overload  your  stomach,  but  get  up  from  the  table  feeling 
that  you  could  eat  a  little  more  with  relish. 

Don't  eat  unripe  or  overripe  fruit. 

Don't  eat  anything,  while  away  from  camp  or  barracks,  whose  ma- 
terials or  mode  of  preparation  may  seem  questionable. 

Don't  bring  worry  or  a  "grouch"  to  table  with  you. 

Excess  in  eating. — ^Overeating  gives  rise  to  biliousness  and  other 
forms  of  dyspepsia  and  overloads  the  body  tissues  with  waste  mat- 
ters. These  wastes  are  irritant  substances  and  are  just  as  likely  as 
alcohol  to  cause  kidney  disease,  gout,  obesity,  and  hardening  of  the 
arteries.     Beefy,  overfed  men  are  especially  liable  to  apoplexy. 

Excess  in  drinking  means,  to  us  all,  overuse  of  drinks  containing 
alcohol  in  some  form.  You  will  learn  that  the  great  majority  of 
violations  of  discipline,  trials  by  courts-martial,  and  subsequent 
punishment  in  our  Army  result  from  this  particular  excess.  Habitual 
indulgence  in  alcohol  brings,  as  certain  rewards,  a  host  of  physical 
and  mental  ailments.  Besides  weakening  men  physically,  alcohol 
tampers  with  their  will  power  and  makes  them  less  trustworthy  even 
when  sober. 

Sexual  indulgence. — It  is  the  popular  idea  that  a  yoimg  man 
must  exercise  the  sexual  function  to  some  extent  in  order  that  he  may 
retain  his  vigor.  This  belief  is  not  founded  on  fact,  for  the  sexual 
act  is  not  necessary  to  preserve  the  health  or  powers  of  a  man.  Not 
only  is  this  true,  but  it  is  equally  true  that  sexual  indulgence  by 
yomig  unmarried  men  is  responsible  for  an  immense  amount  of  dis- 
ease and  suffering.  This  disease  and  suffering  is  borne  not  only  by 
the  men  themselves,  but,  in  a  large  proportion  of  cases,  by  the  inno- 
cent women  whom  they  afterwards  marry  and  by  their  children. 
The  wives  may  be,  and  often  are,  infected  years  after  an  apparent  cure 
has  resulted  and  the  children  are  bom  diseased. 

Clothing. — The  prime  purpose  for  which  clothing  is  worn  (other 
than  that  of  decency)  is  to  afford  protection  to  the  body  against  ex- 
tremes of  cold  and  heat.  The  materials  used  should,  therefore,  be 
such  as  to  conserve  the  natural  warmth  of  the  body  or  to  aUow  it  to 
escape   freely,    in    accordance   with   weather    conditions.     Clothing 


12  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

should  not  bo  permitted  to  interfere  with  the  circulation  of  the 
blood,  nor  with  the  normal  movements  of  the  body. 

Excretory  functions. — Our  bodies,  in  the  work  their  various 
parts  must  perform,  manufacture  certain  waste  products  which  we 
call  excretions.  Now,  it  is  evident  that  if  we  do  not  get  rid  of  these 
substances,  they  will  clog  up  the  body  or  even  act  as  poisons.  Nature 
has,  therefore,  designed  certain  avenues  of  escape  for  these  excretions, 
and  the  chief  of  these  are  the  skin,  the  kidneys,  the  bowels,  and  the 
hmgs.  The  importance  of  the  skin  has  already  been  dwelt  upon. 
The  kidneys  can  best  be  kept  in  good  condition  by  drinking  plenty 
of  water  (at  least  6  or  8  glasses  a  day),  which  flushes  these  organs  and 
dilutes  the  solid  impurities  of  the  urine.  Constipation  induces  a 
variety  of  uncomfortable  conditions,  among  which  piles,  headache, 
the  state  often  called  "biliousness,"  and  mental  depression  are  fre- 
quent.    Therefore,  remember  to  keep  your  bowels  open. 

Lungs. — Tlie  lungs  are  an  important  avenue  of  escape  for  jcertain 
waste  products,  cliief  of  which  is  carbon  dioxide.  The  ventilation  of 
living  rooms  thus  becomes  desirable  to  dilute  or  carry  off  these  wastes, 
to  renew  that  most  vital  element,  oxygen,  and  to  prevent  overheated 
and  undue  moisture  of  the  atmosphere,  which  latter  are  important 
f actoi-s  tending  to  the  diminution  of  vitality.  The  germs  of  diseases 
which  affect  the  respiratory  tract  are  thi*own  off  into  the  air  and  are 
hkely  to  be  breathed  by  healthy  individuals,  who  are  thus  in  turn 
infected.  "Colds"  result  more  often  from  overheated,  poorly  venti- 
lated rooms  than  as  the  result  of  drafts  and  chilhng.  Such  colds  are 
often-  contagious.  The  transmission  of  tuberculosis  and  such  acute 
infectious  diseases  as  measles,  scarlet  fever,  influenza,  and  whooping 
cough  is  favored  by  poor  ventilation. 

Exercise. — A  sufficient  amount  of  exercise  to  maintain  health  is 
ordinarily  provided  by  military  drills  and  other  duties  requiring  active 
movement.  Nevertheless,  the  physical  condition  is  f  ui'ther  improved, 
muscular  size  and  strength  greatly  increased,  and  the  mental  outlook 
rendered  more  cheerful  by  athletic  exercises,  whether  in  the  open  air 
or  the  gymnasium.  A  proper  appreciation  of  the  benefits  of  physical 
exercise  may  be  gained  by  a  mental  comparison  between  the  rugged 
condition  of  a  man  who  exercises  regularly  and  the  poorly-developed 
muscles  and  shallow  skin  of  another  who  has  some  occupation  which 
keeps  hira  indoors  at  work  of  a  light  sort.  The  improvement  is 
brought  about  by  the  increased  activity  not  merely  of  the  muscles, 
but  of  every  part  of  the  body,  including  the  heart,  lungs,  skin,  digestive 
apparatus,  etc.  Like  all  good  things,  however,  exercise  may  be  over- 
done; excessive  rapidity  or  irregularity  of  the  heart's  action  and  la- 
bored breathing  are  warnings  to  stop  and  rest.  Soldiers  in  campaign 
especially  immature  boys,  who  are  sometimes  enlisted  are  very  liable 
to  heart  strain  and  an  "irritable"  condition  of  that  organ. 


MILITARY   HYGIENE.  13 

Artekies. — "A  man  is  as  old  as  his  arteries,"  and  some  men  grow 
old  in  this  respect  much  sooner  than  the  average,  so  care  must  be 
taken  to  suit  the  exercise  to  their  condition. 

The  amount  and  kind  of  exercise  best  suited  to  each  must  be  deter- 
mined, as  these  vary  widely  in  different  individuals.  There  are  men 
who  require  the  equivalent  of  a  brisk  15-mile  daily  walk  to  keep  in  a 
satisfactory  physical  state,  while  the  ordinary  occupation  of  others 
sullices  to  maintain  them  in  excellent  health. 

Rest. — For  the  repair  of  damaged  tissues  and  the  relief  of  fatigue 
a  certain  amount  of  rest  for  both  mind  and  body  is  necessary.  Differ- 
ent people  vary  considerably  in  their  requirements,  but  it  may  be 
set  down  as  a  fair  average  that  8  hours  of  sleep  in  each  24  hours  are 
needed  to  keep  the  faculties  at  their  best.  In  addition  work  of  any 
sort,  physical  or  mental,  must  be  intermitted  by  brief  period  of  relaxa- 
tion. Mental  overwork  is  very  common  in  these  days  of  complex 
civihzation,  and  exhaustion  of  the  nervous  system  (neurasthenia) 
takes  a  long  time  for  its  recovery. 

Recreation. — The  risk  of  overtaxing  the  mind  is  greatly  lessened 
by  measures  of  recreation,  which  may  take  any  proper  form  most 
agreeable  to  the  individual.  The  cultivation  of  a  fad  is  of  especial 
value.  The  habit  of  worry,  of  ''crossing  bridges  before  one  comes  to 
them,"  must  be  avoided.  Fits  of  ''the  blues,"  if  yielded  to,  tend  to 
increase  in  number  and  length  and  finally  to  unfit  one  for  work.  In 
garrison,  on  transports,  and  particularly  in  winter  camps  during  war 
time  we  must  make  provision  for  measures  of  recreation.  These  are 
essential  to  promote  cheerfulness  and  contentment  and  to  lessen  the 
tendency  to  abuse  of  alcohol  and  tobacco,  gambling,  and  perversion 
of  the  generative  function.  Entertainments  of  aU  sorts,  but  more 
particularly  those  participated  in  by  the  men  themselves,  compe- 
titions and  contests,  reading  rooms,  and  opportunities  for  following 
and  learning  mechanical  trades  must  be  provided. 

Cleanliness  of  surroundings. — It  is  not  sufficient  merely  to 
keep  our  bodies  in  a  state  of  cleanliness  by  the  measures  previously 
outhned.  We  must  also  keep  our  surroundings — the  house  and 
grounds  in  which  we  live — ^well  "poUced,"  as  the  expression  goes  in 
our  mihtary  service.  It  is  self-evident  that  where  people  five — ■ 
especially  where  many  people  are  congregated  in  a  small  space — 
there  much  dirt  wiU  collect.  This  refers  not  so  much  to  earthly 
particles  as  to  the  so-caUed  organic  materials  which  are  derived 
from  animal  and  vegetable  sources.  Under  this  head  faU  the  body 
discharges,  refuse  from  the  kitchen,  decaying  flowers  and  weeds, 
cigar  stubs,  floor  and  stable  sweepings,  and  the  hke.  These  must  be 
received  in  vessels  specially  kept  for  them  and  frequently  removed, 
or  they  give  off  foul  odors,  poUute  the  ground,  attract  hosts  of  flies, 
and  act  as  breeding  places  for  the  germs  of  chsease. 


14  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

PREVENTABLE  DISEASES. 

In  the  first  place,  the  fact  must  be  recognized  that  there  are  no 
diseases  peculiar  to  soldiers.  There  is  not,  by  reason  of  their  occu- 
pation or  mode  of  life,  any  abnormal  physical  condition  engendered 
which  has  not  its  counterpart  among  civihans.  On  the  other  hand, 
there  are  certain  departures  from  a  state  of  health  to  which  soldiers 
are  especially  hable  because  of  their  work  and  envii'onment.  Newly 
raised  troops  and  recruits^  generally  have  the  highest  disease  rates. 
Old  soldiers  are  inured  to  service  and  have  learned  how  to  care  for 
themselves. 

Dependency  of  soldiers. — ^''The  men  who  compose  an  army  are 
drawn  from  civil  hfe,  in  which  each  individual  has,  to  a  greater  or 
less  extent,  independent  control  of  his  time,  choice  of  occupation, 
selection  of  food  and  dwelling  place,  and  general  sanitary  care. 
After  erdistment,  soldiers  lose  most  of  this  independence;  they  are 
housed,  clothed,  fed,  and  exercised  under  regulations  which  it  is  be- 
yond their  power  to  amend;  they  are  moved  from  one  point  to  an- 
other, differing  perhaps  very  widely  in  climatic  and  other  conditions, 
under  orders  which  they  may  not  presmne  to  question;  their  hours 
for  sleep,  meals,  work,  and  recreation  are  fixed  for  them  without 
consultation  with  them  or  without  regard  to  individual  or  com- 
munal preference."     (Harrington.) 

Inexperienced  soldiers. — ^In  our  mihtary  system  the  absolute 
dependence  on  the  wiU  or  neglect  of  a  superior  is  especially  prone  to 
result  in  disease  conditions,  because  of  the  ignorance  and  inexperi- 
ence of  mihtia  and  volunteers  suddenly  called  into  active  service. 
The  officers  have  Httle  or  no  knowledge  of  the  care  of  troops,  while 
the  men  exhibit  a  recklessness  and  disregard  for  the  laws  of  health 
peculiarly  national.  The  American  volunteer,  unless  firmly  com- 
manded, displays  the  utmost  incUfference  to  the  ordinary  rules  of 
decency.  He  deposits  his  excrement  where  he  happens  to  be;  he 
drinks  of  any  hquid  he  encounters  which  may  be  dignified  by  the 
name  of  water;  he  thi-ows  his  wastes  indiscriminately  upon  the  camp 
ground,  heedless  of  the  fact  that  putrefactive  changes  wiU  shortly 
make  them  offensive;  he  gleefully  seeks  opportunities  for  alcohohc 
and  sexual  excesses;  and,  in  defense  of  his  heaven-born  liberties,  he 
often  declines  to  mend  his  ways  because  he  enlisted  to  fight  and  not 
to  perform  menial  occupations.  The  necessity  on  the  part  of  fine 
officers  for  familiarity  with  the  preventable  diseases  to  which  the 
soldier  is  Hable  and  with  the  fundamental  sanitary  principles  neces- 
sary for  their  prevention  thus  becomes  apparent. 

Venereal  disease. — Of  all  the  ills  from  which  the  soldier  suffers, 
those  consequent  upon  venery  affect  his  efficiency  to  the  greatest 
extent.  Om-  Army  is  made  up  mainly  of  young,  unmarried  men 
freed  from  the  moral  restraints  of  home,  often  without  opportmiity 


MILITARY   HYGIENE.  15 

for  association  with  decent  women  and  susceptible  to  the  suggestion 
of  the  vicious.  There  must  be  some  outlet  for  their  siu-plus  energies. 
They  visit  places  of  amusement,  many  of  which  are  maintained  with 
the  sole  object  of  pandermg  to  vice,  where  strong  hquor  and  the 
advances  of  lewd  women  combine  to  break  down  such  moral  defenses 
as  they  may  possess.  Unless  prevented  by  legal  enactment  the  low- 
est kinds  of  "dives"  cluster  round  the  entrances  to  Army  posts. 
The  soldier  has  a  right  to  his  amusements,  and  we  must  strive  to 
furnish  such  as  will  attract  him  more  than  evil  resorts,  to  secure  the 
passage  of  laws  preventing  the  estabhshment  of  low  brothels  at  our 
gates,  and  to  build  up  the  moral  stamina  of  our  men  by  education. 

Statistics  show  that  at  least  a  third  of  all  women  who  give  their 
bodies  for  immoral  purposes  are  suffering  from  some  form  of  venereal 
disease.  This  includes  not  merely  the  professional  prostitute,  but 
the  chorus  girl,  "saleslady,"  or  mill  hand,  who,  to  satisfy  her  love 
for  finery  or  for  other  reasons,  may  eke  out  a  scanty  income  by 
occasional  lapses  from  virtue.  It  is  a  medical  axiom  that  every 
prostitute  becomes  infected  with  syphihs  inside  of  two  or  three  years. 
It  is  therefore  easy  to  see  that  the  risks  of  contagion  are  very  great. 

Tlie  American  people  have,  xmtil  recently,  shunned  pubhc  discus- 
sion of  venereal  matters  through  what  may  now  seem  to  have  been 
mistaken  prudery.  A  great  movement  has  lately  been  instituted, 
through  the  American  Association  for  Sex  Hygiene  and  allied  societies, 
looking  to  the  awakening  of  the  pubhc  conscience  and  the  moral 
education  of  the  youth  of  the  land. 

Prevalence  in  the  Army. — Venereal  infections  are  responsible 
for  an  enormous  amount  of  sickness  in  the  Army— vastly  more  than 
any  other  cause — and  constitute  the  most  important  health  problem 
with  which  we  have  to  deal.  There  are  constantly  on  the  sick  report 
from  this  cause  a  number  of  men  which  more  than  equal  the  strength 
of  a  regiment  of  Infantry.  Our  Army  has  the  unenviable  distinction 
of  having  much  greater  amount  of  sickness  of  this  nature  than  any 
foreign  army.  Moreover,  since  the  Spanish-American  War  the  ratio 
of  such  cases  has  rapidly  increased,  until  it  is  now  twice  as  much  as 
in  1898.  The  situation  must  therefore  be  fairly  faced  and  every 
effort  put  forth  to  determine  the  causes  for  the  prevalence  of  venereal 
diseases  and  to  devise  measures  for  their  prevention. 

That  the  Army  has  a  greater  percentage  of  such  disease  than  has 
an  equal  number  of  vigorous  young  unmarried  men  drawn  from  hke 
source  in  civil  hfe  is  not  behoved.  Such  infections  cause  the  largest 
proportion  of  rejections  of  apphcants  for  enhstment.  They  honey- 
comb oiu-  social  structm-e.  In  point  of  prevalence  they  vastly  out- 
number aU  other  infectious  diseases,  both  acute  and  chronic  combined. 

Causes. — These  are  not  far  to  seek.  In  the  first  place,  sexual 
desire  is  implanted  in  man  as  a  compelling  factor  for  the  perpetuation 


16  MILITARY    SANITATION    AND    SANITAEY    SERVICE. 

of  the  race.  This  desn-e  is  strong,  especially  when,  by  previous  exer- 
cise of  the  function,  the  habit  has  been  formed.  Next,  the  demand 
for  partners  in  the  sexual  relation  has  always  created  a  supply,  and 
prostitution  is  as  ancient  as  history.  Of  late  this  supply  has  been 
elevated  to  the  dignity  (?)  of  a  business,  and  a  hideous  traffic,  with 
an  mtricate  system  for  procuring  young  girls  and  suborning  those 
who  legally  should  prevent  such  traffic,  is  now  strongly  intrenched. 

Preventive  measures. — How,  then,  shall  we  set  about  to  mini- 
mize, as  far  as  possible,  the  incidence  and  effects  of  these  loathsome 
diseases,  largely  dependent,  as  they  are,  upon  causes  inlierent  in  the 
nature  of  mankind  ?  From  a  sanitary  standpoint  it  is  plain  that  we 
must  apply  the  ordinary  principles  of  sanitation.  That  is,  we  must 
recognize  their  contagious  character  and  apply  such  preventive 
measures  as  are  effective  in  other  transmissible  diseases.  The  most 
important  measure  of  this  character  is  the  isolation  of  infected  indi- 
viduals until  the  danger  of  transmission  is  past.  In  the  Ai-my  we  can 
and  do  control  our  infected  soldiers,  but  the  women  from  whom  their 
disabifities  were  derived,  as  well  as  infected  male  civifians,  are  still  at 
large  to  spread  the  contagion  further.  It  is  obvious,  therefore,  that, 
if  we  hope  for  success,  sentimentalism  and  prudery  must  give  way, 
and  that  diseased  pubhc  women  must  be  admitted  to  hospitals  or 
otherwise  placed  under  restraint  tiU  the  infectious  stage  of  the  disease 
is  over.  For  the  diseased  male,  it  should  be  made  a  crime  knowingly 
to  spread  a  venereal  disease. 

Education. — The  measures  above  outlined  do  not  conform  with 
the  yet  uneducated  pubhc  feeling  that  it  is  immoral  to  openly  recog- 
nize diseases  of  this  class  and  their  chief  transmitter,  the  prostitute. 
On  the  other  hand,  the  measures  themselves  are  certainly  not  immoral, 
while  they  are  practical.  On  the  moral  side,  the  camj^aign  of  educa- 
tion already  begun  should  be  extended  and  a  flood  of  fight  poured 
upon  the  subject,  that  all  may  clearly  understand  sex  matters,  the 
dangers  as  well  as  the  immorafity  of  iUicit  intercourse  and  the  methods 
of  spread  of  diseases  transmitted  thereby.  With  such  education,  the 
veil  of  ignorance,  misiriformation,  and  prudery  will  be  lifted  and  the 
tendency  to  secret  vices  among  children  will  be  lessened.  Havard 
says  truly:  '' It  is  in  the  conscience  of  the  young  man  that  prophylaxis 
shoidd  begin."  The  knowledge  of  sexual  matters  acquu'ed  bj^  a  child 
is  from  bad  sources  and  of  a  perverted  kind.  Such  knowledge,  secretly 
acquired  and  brooded  over  in  secret,  hastens  the  awakening  of  sexual 
feclmg  and  leads  to  vice. 

Action  by  tue  War  Department. — Our  War  Department  has 
acted  with  courage  and  vigor  in  attacking  this  problem.  Orders  were 
issued  in  1912  directing  procedures  as  foUows: 

I.  That  physical  inspections  of  enlisted  men  should  be  made  twice 
each  month  for  the  detection  of  venereal  disease. 


MILITARY   HYGIENE.  17 

II.  That  any  soldier  who  exposes  himself  to  infection  shall  report 
for  cleansmg  and  preventive  treatment  immediately  upon  return  to 
camp  or  garrison. 

III.  That  any  soldier  who  fails  to  so  report,  if  found  to  be  suffering 
from  a  venereal  infection,  shall  be  brought  to  trial  by  court-martial 
for  neglect  of  duty. 

IV.  That  men  so  diseased  shall  be  confined  strictly  to  the  limits 
of  the  post  during  the  infectious  stages  of  the  disease. 

V.  That  all  officers  servuig  with  troops  shaU  do  their  utmost  to 
encourage  healtliful  exercises  and  physical  recreation  and  to  supply 
opportmiities  for  cleanly  social  and  interesting  mental  occupations 
for  the  men  under  their  command. 

VI.  That  company  and  mecUcal  officers  shall  take  advantage  of 
favorable  opportunities  to  point  out  the  misery  and  disaster  which 
follow  upon  moral  uncleanliness  and  the  fact  that  venereal  disease 
is  never  a  trivial  affaii*. 

Action  by  Congress. — Congress,  too,  has  taken  a  decided  stand, 
by  an  enactment  providing  that  no  officer  or  enfisted  man  who  shall 
be  absent  from  duty  on  account  of  disease  resulting  from  his  own 
intemperate  use  of  drugs,  or  alcohofic  Hquors,  or  other  misconduct, 
shall  receive  pay  for  the  period  of  such  absence. 

It  will  be  seen  from  the  foregomg  that  the  Army  now  has  an 
excellent  plan  for  the  discouragement  of  vice  and  the  control  of 
cUsease  resulting  therefrom.  To  add  to  the  effectiveness  of  this  plan, 
efforts  are  being  made  to  induce  Congress  to  repeal  the  anticanteen 
legislation,  thus  again  permitting  the  sale  of  beer  and  light  wines 
in  the  soldiers'  clubs  and  cooperative  stores  officially  known  as  post 
exchanges.  It  is  not  here  argued  that  the  canteen  is  an  unmixed 
good  nor  that  drinking  should  be  encouraged.  It  is,  however,  in 
the  highest  degree  desirable  to  keep  the  men  away  from  more  evil 
influences,  and  it  is  notorious  that  the  saloon,  prostitution,  and  pro- 
fessional gambling  go  hand  in  hand.  The  close  relation  betw^een 
alcohofic  excess  and  sexual  indulgence  is  an  interesting  fact.  A 
man's  passions  are  inflamed  by  licjuor,  his  wiU  power  and  his  judgment 
are  afike  weakened,  and  he  yields  to  conditions  which  in  his  sober 
moments  might  be  positively  offensive  to  Mm. 

Syphilis. — There  are  three  kinds  of  venereal  disease.  The  most 
serious  to  man  is,  perhaps,  syphilis  (sometimes  called  the  ''pox," 
and  referred  to  in  the  newspaper  advertisements  of  charlatans  as 
"blood  disease").  This  is  due  to  a  very  active,  corkscrew-shaped 
protozoal  germ.  Its  first  apparent  result  is  an  open  sore  at  the  point 
of  infection.  This  sore,  known  as  a  hard  chancre,  does  not  appear 
for  several  weeks  after  exposure,  but  is  then  very  resistant  to  treat- 
ment and  remains  for  a  month  or  more.  The  body  is  soon  infected 
98756°— 17 2 


18  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

throughout,  and  symptoms  of  this  condition  appear  most  often  in 
the  form  of  skin  eruptions  and  glandular  swellings. 

Syphilis  is  an  infection  of  the  entire  system  and  its  manifestations 
are  practically  innumerable.  We  may  expect  it  to  appear  in  any 
conceivable  form,  and  where  a  chronic  case  of  disease  is  obscure, 
tests  often  reveal  its  presence.  Certain  of  these  manifestations  may 
(and  do)  appear  many  years  after  the  disease  was  contracted.  Among 
these  are  paresis  (softening  of  the  brain)  and  locomotor  ataxia. 

Syphihs  is  extremely  difficult  to  cure,  and,  in  a  certain  proportion 
of  cases,  never  is  cured.  The  new  remedy — ^^'606"  or  salvarsan — is 
stiU  in  the  experimental  stage,  but  it  is  at  least  certain  that  its  use 
is  not  followed  by  permanent  recovery,  and  that  the  older  and  more 
prolonged  forms  of  treatment  must  still  be  employed.  Syphihs  is 
the  disease  which  is  so  often  transmitted  to  the  children — ^''even  unto 
the  third  and  fourth  generation,"  as  the  Good  Book  informs  us — 
as  well  as  to  the  wife.  It  may  be  transmitted  to  others  not  only  by 
sexual  contact,  but  also  by  means  of  articles  (such  as  towels,  eating 
and  drinking  utensils,  a  comrade's  pipe)  used  in  common.  Cases 
also  are  frequently  met  which  have  been  innocently  acquired 
through  kissing,  surgical  or  dental  operations,  the  ministrations  of  a 
nurse,  and  numerous  other  blameless  ways. 

The  danger  of  transmission  of  the  disease  from  father  to  cliild 
(hereditary  syphilis)  is  very  considerable.  Many  childi-en  are  born 
dead;  others  die  soon  after  birth;  still  others  (who,  though  diseased, 
may  survive)  show  characteristic  deformities  or  unmistakable 
syphihtic  lesions. 

Marriage. — ' 'Marriage  of  a  syphilitic  is  permissible  only  after  five 
years,  during  the  last  two  of  which  he  has  been  without  symptoms 
and  without  treatment"  (Keyes). 

Gonorrhea,  or  "clap,"  is  the  result  of  infection  with  the  bacterial 
germ  known  as  the  gonococcus,  and  is  characterized  by  a  profuse 
pm-ulent  discharge  from  the  affected  part.  This  is  usually  the  canal 
of  the  penis  (the  urethra)  in  the  male,  although  any  mucous  or  serous 
membrane  may  be  involved.  Thus  if,  by  carelessness  or  misfortune, 
a  little  of  the  pus  is  transfen-ed  to  the  eye,  a  most  violent  inflamma- 
tion ensues  and  the  sight  is  in  grave  danger  of -destruction.  Gonor- 
rheal rheumatism  is  a  common  and  intractable  affection.  Heart 
disease  is  an  occasional  sequel. 

Gonorrhea  is  even  more  frequently  conveyed  to  the  wife  than 
syphilis,  and  with  most  serious  results,  as  thousands  of  deaths  and 
tens  of  thousands  of  chronic  invalids  attest;  60  to  80  per  cent  of  pelvic 
suppm-ations  in  women  are  due  to  this  affection.  The  eyes  of  babies 
become  infected  during  birth.  It  is  estimated  that  25  per  cent  of 
blind  people  owe  their  infirmity  to  this  cause. 


MILITARY    HYGIENE.  19 

Gonorrhea  is  popularly  regarded  as  something  of  a  joke,  an  affec- 
tion but  little  more  harmful  than  a  cold  in  the  head;  but  many  sur- 
geons look  upon  it  as  more  serious  than  syphilis  in  its  results,  for  the 
infection  has  a  way  of  traveling  along  the  various  routes  to  the 
bladder,  kidneys,  and  testicles,  leaving  a  man  permanently  injured 
and  often  greatly  shortening  his  life.  Gonorrhea  is  transmitted  to 
innocent  people — wife,  child,  comrade — with  extreme  ease,  so,  if 
thus  affected,  one  can  not  be  too  careful  to  make  sure  that  none  of  the 
discharge  is  brought  in  contact  with  a  healthy  individual.  Cotton  or 
other  material  soiled  with  the  discharge  should  be  burned  or  otherwise 
safely  disposed  of. 

Chancroid. — The  third  venereal  disease— chancroid  or  soft 
chancre — is  a  contagious  ulcer.  It  is  always  local,  never  constitu- 
tional, and  has  no  relation  to  syphilis  (although  it  is  frequently  nec- 
essary to  wait  for  weeks  before  one  can  be  sure  it  is  not  the  latter). 
Its  cause  is  a  special  bacillus.  While  it  may  occur  elsewhere,  it  is 
practically  always  found  about  the  genitals.  Though  less  serious 
than  the  other  diseases  of  this  class,  it  is  a  painful  and  repulsive 
affection.  In  about  one-third  of  the  cases  it  is  accompanied  by  an 
abscess  m  the  groin  known  as  a  bubo. 

Personal  prophylaxis. — Reference  has  been  made  earlier  in  this 
lecture  to  the  War  Department  requirement  that  enlisted  men  who 
have  exposed  themselves  to  venereal  infection  shall  report  at  hospital 
or  dispensary  for  cleansing  and  preventive  treatment,  but  it  may  be 
said  that  the  procedures  used  are  very  successful  in  the  prevention  of 
infection.  Objection  has  been  made  that  such  prevention,  by  making 
licentiousness  safe,  encourages  the  latter.  As  already  shown,  our 
problem  is  to  keep  om'  soldiers  physically  fit,  and  purely  sentimental 
considerations  are  of  secondary  importance.  Moreover,  our  Navy- 
has  given  the  system  a  fair  trial,  and  finds  an  actual  diminution  in 
percentage  of  exposures  as  the  result  of  the  campaign  of  education. 

In  the  absence  of  legitimate  intercourse  (that  is,  married  fife) 
natm'e  will  relieve  the  situation  by  an  occasional  nocturnal  emission, 
which  is  in  no  sense  harmful.  The  cultivation  of  pure  thought,  the 
avoidance  of  temptation,  cold  baths,  simple,  nonstimulating  diet, 
vigorous  physical  exercise,  and  alcohohc  abstinence  will  prove  effi- 
cacious in  overcoming  desire. 

TYPHOID  FEVER. 

Typhoid  fever  (or  enteric,  as  the  Enghsh  call  it)  has  for  many  years 
been  known  as  "  the  scourge  of  armies."  In  our  Civil  War  the  Union 
Army  had  over  80,000  cases  recognized  as  such,  and  there  were 
probably  as  many  more  which,  because  of  imperfect  means  of  diag- 
nosis, were  thought  to  be  malaria  and  other  infections. 


20  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

War  of  1870. — The  Germans,  in  tlie  war  with  France  in  1870,  had 
over  73,000  cases  and  nearly  7,000  deaths,  although  active  hostihties 
lasted  but  six  months. 

Boer  War. — ^The  British  Army  in  South  Africa,  while  fighting 
with  the  Boers,  had  57,000  cases  and  8,000  deaths. 

War  of  1898. — ^In  our  war  with  Spain  we  had  20,738  cases,  with 
1,580  deaths,  among  108,000  men,  all  occurring  within  three  and  a 
half  months;  1  man  in  every  6  had  the  chsease,  while  this  proportion 
was  increased  to  1  in  5  among  those  regiments  which  never  left  the 
United  States.  Typhoid  fever  caused  nine-tenths  of  all  deaths  occur- 
ring among  troops  encamped  in  the  United  States  in  1898. 

Such  instances  might  be  multiphed  indefinitely,  but  enough  has 
been  said  to  show  what  an  immense  amount  of  sickness  and  mihtary 
inefficiency — ^to  say  nothing  of  the  suffering  and  death  of  individuals, 
with  economic  loss — ^this  dreaded  disease  causes. 

How  spread. — Typhoid  baciUi  find  the  most  favorable  soil  for 
growth  and  increase  in  the  bowels  of  human  beings;  they  are  usually 
found  also  in  the  lu'ine  of  infected  individuals.  The  disease  is  spread, 
therefore,  by  the  discharges  of  such  individuals  gaioing  access  to  the 
intestinal  canals  of  others  through  swallowing  substances  contami- 
nated with  the  germ.  This  may  happen  directly  by  contact  with  a 
diseased  person  or  indirectly  through  infected  water,  nulk,  uncooked 
fruit  and  vegetables,  dust,  flies,  soiled  hands,  garments,  bedding,  or 
tentage. 

If  we  had  a  perfect  method  of  disposal  of  these  waste  products  of 
the  body,  it  would  not  be  long  before  typhoid  fever  would  cease  to 
appear  in  epidemic  form,  and  only  an  occasional  case  would  be  en- 
countered as  the  result  of  direct  contact  with  an  infected  inchvidual. 
But,  under  the  imperfect  sanitary  conditions  of  modern  existence,  it 
will  be  a  long  time  before  this  is  reahzed,  and  in  the  meanwhile  we 
must  employ  such  measures  as  will  reduce  to  a  minimmu  the  risks  of 
contact  with  infectious  material. 

Army  epidemics. — ^Typhoid  fever  is  more  hkely  to  become  epi- 
demic in  mditary  than  in  civil  life  because  of  the  greater  difficulty  in 
cUsposing  of  wastes  and  the  close  crowding  and  intimate  contact  of 
yomig  men  under  the  conditions  of  camp  and  barrack  life.  A  man 
affected  with  typhoid  may  scatter  the  germs  of  the  disease  widely 
before  its  existence  is  recognized  in  himself,  since  it  frequently  hap- 
pens that  mild  cases  are  not  detected  for  a  week  or  two  from  their 
onset.  Moreover,  3  to  4  persons  in  every  100  who  have  recovered 
from  attacks  continue  to  breed  the  germs  in  their  bodies  and  to  dis- 
charge them  with  their  excretions.  We  call  such  chronically  infected 
inchviduals  carriei'S.  Such  a  man,  by  defecating  in  the  nearest  brush, 
step])ing  just  outside  his  tent  at  night  to  urinate,  or  fafling  to  cover 
his  chscharges  in  the  sink  (whereby  ffies  may  have  access  to  them,  to 


MILITARY    HYGIENE.  21 

convey  the  filth  to  food  in  near-by  kitchens  a  httle  later)  may  he 
sowing  the  seeds  of  the  scourge  broadcast.  Each  man  who  thus 
oflfends  seems  to  think  he  is  the  only  one  who  does  such  a  trick  and  so 
it  won't  do  any  harm.  Unfortunately,  many  of  hLs  comrades  are 
looking  at  the  matter  from  the  same  point  of  view.  And  fhes  are  not 
necessarily  the  agents  in  this  matter.  Let  us  again  assume  one  in- 
fected individual  in  camp.  His  habits  as  to  cleanliness  may  be  bad 
or  his  opportunities  therefor  poor.  At  any  rate,  his  hands  are  sure 
to  be  soiled  with  infectious  material,  which  he  transfers  to  everything 
he  touches — <lothing.  bedding,  towel,  the  cigars  or  matches  he  proffers 
to  a  comrade,  and  even  the  food  of  others  which  he  handles — ^for  he 
may  be  company  cook  or  cook's  police.  His  saliva  is  infectious  and 
he  fouls  the  common  drinking  cup  or  a  pipe  which  another  may  use. 
Or,  again,  a  solchers  shoes  may  be  soiled  with  the  filth  deposited  upon 

le  ground  by  a  careless  comrade.  This  material  is  carried  about  the 
V  amp  and  into  the  tents,  and.  since  the  typhoid  bacillus  may  live  for 
a  time  in  the  earth,  a  puff  of  wind  of  a  friendly  scuffle  whirls  the 
infected  dust  in  the  air.  whence  it  is  likely  to  be  blown  upon  food  and 
thus  swallowed.  By  such  means  not  one  but  dozens  of  men  are 
infected,  and  with  each  new  case  the  risks  grow  in  geometric  progres- 
-  >n.  In  the  multitude  of  cases  during  the  Spanish- American  War 
impure  water  played  little  or  no  part.  The  three  factors  almost  wholly 
responsible  for  these  cases  were  uncovered  excreta,  flies  attracted 
t-iereby.  and  personal  contact  with  infected  individuals. 

Peevextiox. — Xow,  what  is  the  ''ounce  of  prevention''  in  this 

-e  '.  It  consists,  first,  in  the  preliminary  antityphoid  vaccination 
uf  men  beUeved  to  be  susceptible;  second,  in  a  campaign  of  educa- 
tion (which  must  be  shared  by  line  and  medical  oflS-cers  alike)  in  the 
facts  just  related;  third,  in  the  protection  of  the  water  supply; 
fourth,  in  the  systematic  and  thorough  disposal  of  excreta  and  or- 
ganic wastes  generally:  and  fifth,  in  sharp  punishment  for  violations 
of  sanitary  regulations. 

AxTTTTPHOED  VACCiXATiox. — ^In  antityphoid  injections  we  now 
have  a  method  of  protection  against  this  disease  which  is  quite  as 
efficacious  as  is  vaccination  against  smallpox.  It  is  well  known  that 
an  attack  of  typhoid  usually  protects  a  man  against  a  subsequent 
attack.  Only  1  case  in  143  has  typhoid  a  second  time,  and  the 
method  of  protection  referred  to  is  found  to  confer  immunity  in  a 
similar  way  and,  it  is  thought,  to  an  equal  degree. 

It  is  in  our  own  service  that  the  procedure  has  been  most  thor- 
oughly tested  and  its  value  definitely  proved.  Vaccinations  of  offi- 
cers and  men  who  volunteered  for  the  purpose  were  commenced  in 
1909.     The  results  were  so  good  that  in  1911  the  procedure  was  made 

mpulsory  for  all  imder  -1-5  years  of  age  who  had  never  had  the  dis- 
ease.    The  Navy  followed  suit,  and  immunization  of  both  services 


22 


MILITARY    SANITATION    AND    SANITARY    SERVICE. 


is  now  practically  complete.  A  single  instance  of  the  value  of  the 
prophylactic  measure  to  our  service  will  suffice.  This  takes  the  form 
of  a  comparison  between  an  Army  division  in  Florida  during  the 
Spanish  War  in  1898  and  a  division  in  Texas  during  the  border  trou- 
bles in  1911.  Conditions  as  to  strength  of  command,  chmate,  sea- 
son, purity  of  water  supply,  and  duration  of  camp  were  approxi- 
mately equal.  The  disposal  of  wastes  was  much  superior  in  the 
latter  camp,  but  the  complete  immunization  of  the  Texas  command 
by  means  of  the  antityphoid  prophylactic  constituted  the  conspicu- 
ous difference. 


Year. 

Mean 
strength. 

Cases  of 

typhoid 

(certain 

and 

probable). 

Deaths 

from 

typhoid. 

1898.... 
1911.... 

10,759 
12,801 

2,693 
2 

248 
0 

LECTURE  II. 
MILITARY  HYGIENE. 

DYSENTERY. 

Dysentery  remains  the  most  serious  of  the  diseases  to  which  our 
people  in  tlie  Phihppines  are  hable.  Broadly  speaking,  dysentery 
is  any  inflammatory  disease  of  the  bowels  in  wliieh  blood  and  mucus 
appear  in  the  stools.  Based  upon  their  causative  factors  there  are 
two  types,  the  one  due  to  animal  (protozoal),  the  other  to  vegetable 
(bacterial)  parasites. 

Amebec  type. — The  prmcipal  form  of  dysentery  under  the  first 
head  is  caused  by  an  ameba,  a  minute  animal  consisting  of  a  single 
cell.  This  is  the  type  which  causes  most  trouble  in  the  Phihppine 
Islands;  it  is  also  met  with  in  our  Southern  States.  The  amebse 
enter  the  body  with  food  or  water  and  produce  inflammations  and 
ulcerations  of  the  large  intestine,  which  are  sometimes  complicated 
by  abscesses  of  the  liver.  Their  natural  home  appears  to  be  the 
human  intestine,  and  from  this  source  they  contaminate  foods 
(especially  fruits  and  green  vegetables)  and  drinking  water. 

Bacillary  type. — The  bacterial  type  of  dysentery  is  caused  by 
the  baciUus  dysenterise.  Bacillary  dysentery  can  only  be  told  from 
the  amebic  form  by  an  expert,  but  for  our  purposes  this  fact  is  unim- 
portant, since  our  preventive  measures  are  the  same  for  both.  This 
type  is  very  widely  distributed  over  temperate  as  weU  as  hot  chmates, 
and  is  the  one  which  is  responsible  whenever  epidemic  outbreaks 
occur  in  an  army.  The  baciUi  are  conveyed  from  fecal  matter  to 
the  mouth  by  contaminated  food  or  drink.  Flies  are  common  agents 
of  transference  and  personal  contact  plays  as  large  a  part  as  in  typhoid. 
As  a  result  of  their  presence  in  the  bowel  and  the  development  of 
poisons  (toxins)  resulting  from  their  activities,  ulcerations  of  the 
large  intestine,  hem^orrhages  therefrom,  and  great  prostration  result. 
This  form  is  usually  more  active  and  dangerous  than  the  amebic, 
being  sometimes  almost  as  rapidly  fatal  as  cholera. 

Camp  diarrheas. — Diarrheas  are  very  common  in  field  service 
and  may  result  from  a  variety  of  causes,  such  as  bad  food,  certain 
kinds  of  water,  poor  cooking,  or  abdominal  chilling.  There  is  also 
an  epidemic  form  (heretofore  referred  to  as  camp  diarrhea)  which 
attacks  large  numbers  of  men  at  one  time  and  is  severe  in  character. 
One  cause  of  epidemic   diarrhea  is   the  dysentery  bacillus,   which 

23 


24  MILITARY    SANITATION    AND    SANITAEY    SEEVICE. 

occasionall}'  manifests  its  activities  thus,  but  any  form  of  diarrhea 
is  bad,  since  it  not  only  rapidly  weakens  a  man,  but,  by  irritating 
the  intestines,  it  increases  the  habihty  to  attack  by  the  more  serious 
affections,  typhoid  fever  and  dysentery.  Under  conditions  of  active 
service  the  importance  of  "carriers"  of  typhoid,  dysentery,  and  epi- 
demic diarrheas  is  greater  than  in  civil  life.  Indeed,  these  probably 
constitute  the  most  important  of  all  factoids. 

Prevention. — Preventive  measures  for  all  forms  of  dysenteries 
and  camp  diarrheas  are  identical  with  those  for  typhoid  fever  save 
in  the  matter  of  vaccination,  for  which  we  do  not  as  yet  possess  an 
efficient  agent.  The  water  supply  should  be  carefully  protected 
from  fouling ;  the  feces  of  men  sick  with  these  diseases  should  be  disin- 
fected or  otherwise  safely  disposed  of;  the  sick  should  be  separated 
from  the  well;  and  all  sources  of  irritation  of  the  intestinal  tract 
should  be  avoided. 

MALARIA. 

The  malarial  fevers  constitute  an  important  class  of  diseases. 
Other  names  by  which  they  are  known  are  ague;  chiUs  and  fever; 
remittent  fever;  intermittent  fever.  The  dreaded  Chagres  fever  of 
Panama  is  a  form  of  pernicious  malaria.  There  are  three  types  of 
these  fevers,  each  due  to  a  different  minute  animal  parasite  which 
attacks  the  blood  of  man,  but  it  is  sufficient  for  our  purpose  here  to 
know  that  all  have  a  similar  origin,  namely,  the  bite  of  an  infected 
mosquito.  The  method  of  transmission  was  discovered  as  recently 
as  1898  by  a  British  Army  surgeon. 

Anopheles  mosquitoes. — Only  one  variety  of  mosquito  (the 
anopheles)  which,  however,  has  rather  numerous  species  is  capable 
of  transmitting  the  germs  responsible  for  the  disease.  The  mos- 
quitoes may  be  recognized,  in  their  adult  or  even  larval  forms,  by 
peculiarities  in  their  attitudes  when  at  rest.  The  larvae  (popularly 
called  "wigglers")  of  harmless  (culex)  mosquitoes  lie  head  down- 
ward in  the  water  in  which  they  are  developing,  with  only  their 
breathing  tubes  in  contact  with  the  sm-face.  Those  of  the  anoph- 
eles lie  parallel  -w^th  the  water's '  surface  and  just  beneath  it. 
Mosquitoes  themselves,  when  resting,  show  opposite  peculiarities; 
that  is,  the  common  forms  lie  parallel  with  the  surface  to  which  they 
chng,  while  the  anopheles  rest  with  their  heads  near  the  surface 
and  their  bodies  anghng  away  from  it.  Another  point  of  difference  is 
that  the  common  form  is  humpbacked,  while  the  anopheles  is  nearly 
straight  from  proboscis  to  tail.  It  is  worthy  of  remark  that  only 
females  are  bloodsuckers  and  thus  transmitters  of  malaria.  The 
male  may  readily  be  recognized  by  the  feathery  tuft  on  his  head. 

Mode  of  transmission.— The  transference  of  the  infection  from 
one  man  to  another  is  accomplished  in  the  following  inamier:  A 
certain  individual  has  malaria,  which  means  that  he  has  in  his  blood 


I 


MILITARY    HYGIENE.  25 

tlie  germs  which  cause  the  disease.  An  anopheles  mosquito  bites 
him  and  draws  into  her  stomach,  along  with  the  blood,  a  number  of 
these  germs,  which  undergo  a  peculiar  form  of  development  witliin 
her  body.  After  this  development  is  complete,  this  mosquito  bites 
a  healthy  man,  and,  injecting  a  little  saliva  through  her  hollow 
proboscis  in  order  to  make  the  blood  more  fluid,  she  thus  presents 
this  second  man  with  a  number  of  undesirable  guests  in  the  shape 
of  malarial  parasites.  These  promptly  attack  such  of  the  red  cor- 
puscles of  his  blood  as  are  most  available,  and  the  cycle  is  complete. 
Thus,  the  conditions  which  must  exist  to  favor  the  spread  of  malaria 
are:  First,  an  infected  human  being;  second,  anopheles  mosquitoes; 
third,  healthy  man;  and  fourth,  opportunity  afforded  to  the  mos- 
quitoes. The  germ  of  the  disease  is  a  microscopic,  single-celled 
animal  (protozoon).  This  germ  was  discovered  in  1880  by  a  French 
army  surgeon. 

Prevention. — Preventive  measures  are  as  follows:  First,  pre- 
caution against  moscjuito  bites  by  the  use  of  screens  for  doors  and 
'VA-indows,  bars  for  beds,  and  head  nets  and  gloves  when  necessary 
at  night;  second,  the  killing  of  mosquitoes  in  houses  by  fumigation, 
trapping,  or  other  means;  third,  the  destruction  of  their  breeding 
places  (i.  e.,  collections  of  standing  water),  associated  ^-ith  the  cut- 
ting of  high  grass  and  underbrush  near  human  habitations;  and 
fourth,  the  routine  administration  (in  malarious  localities)  of  small 
doses  of  quinine  to  officers  and  men  and  attached  civilians.  Wlien 
an  individual  is  known  to  be  infected,  he  should  be  screened  wdth 
especial  care  to  prevent  access  of  mosquitoes  to  him.  Gen.  Gorgas 
is  of  the  opinion  that  when  troops  are  marching  through  a  malarious 
country  the  only  practical  measure  for  their  protection  is  the  ad- 
ministration of  quinine.  The  theory  of  this  procedure  is  that  when 
the  malarial  parasites  are  introduced  into  the  blood,  they  find  there 
a  substance  hostile  to  them.  He  says  fm-ther,  that  such  anopheles 
mosquitoes  as  may  bite  soldiers  in  campaign,  would  not  likely  be 
infected  unless  the  troops  are  quartered  in  or  camped  near  some 
town.  If  the  camp  is  occupied  for  more  than  a  day  or  two  the 
ground  should,  of  course,  be  cleared  and  accumulations  of  water 
di-ained  away  or  oiled. 

TUBERCULOSIS. 

Tuberculosis  is  what  is  commonly  known  as  ''consumption,"  be- 
cause of  the  wasting  away  of  the  body,  which  is  an  invariable  accom- 
paniment. The  tubercle  bacillus,  wliich  is  responsible  for  tliis  disease, 
may  and  does  attack  any  part  of  the  human  body,  but  tuberculosis 
of  the  lungs  so  greatly  preponderates  that  when  we  apply  the  term  the 
pulmonary  variety  is  generally  meant.  Tliough  tliis  affection  may 
result  from  food  (especially  milk)  containing  the  tubercle  bacillus, 


26  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

the  usual  channel  of  infection  is  by  way  of  the  lungs,  the  germs  being 
carried  in  the  air.  A  soldier  with  the  disease  may,  before  the  condi- 
tion is  suspected,  infect  the  air  of  his  squad  room  to  such  a  degree  that 
all  other  susceptible  individuals  therein  may  contract  the  disease. 

Coughing  and  spitting. — The  germs  are  coughed  up  from  their 
seat  in  the  lungs ;  the  spitting  habit,  as  we  know,  is  one  deeply  en- 
grafted upon  the  American  male;  the  germs  resist  death  by  drying  to 
a  remarkable  degree.  We  are  therefore,  Ukely  to  have  in  barracks 
the  conditions  best  suited  to  the  spread  of  this  disease,  namely,  a  num- 
ber of  susceptible  individuals  closely  aggregated,  an  infected  man 
who  scattere  his  sputum  carelessly  about,  and  close  air,  breathed  over 
and  over  because  of  the  inadequate  ventilation  so  dear  to  the  average 
crowd. 

Prevention. — The  information  just  given  readily  suggests  the 
means  to  be  employed  to  prevent  the  spread  of  this  affection,  which 
are:  First,  the  exercise  of  great  care  in  recruiting,  to  exclude  those  in 
the  early  stages  of  the  disease;  second,  the  early  recognition  of  such 
cases  in  the  mihtary  service,  with  their  removal  to  a  special  hospital; 
to  this  end,  noncommissioned  officers  should  be  required  promptly  to 
report  any  man  who  has  a  persistent  cough;  third,  ample  air  space 
per  man  in  barracks;  fourth,  adequate  ventilation  must  be  provided 
for  and  its  mechanism  carefully  guarded  to  insure  its  continuous 
operation.  In  this  connection  it  is  well  to  state  that  in  our  service 
the  guardhouse  is  the  place  most  commonly  infected,  since  it  is  usually 
overcrowded  and  the  men  of  most  careless  habits  are  apt  to  be  im- 
mured therein. 

TONSILITIS. 

TonsiHtis  and  other  throat  affections  are  very  common  in  barracks 
during  cold  weather  and  frequently  occur  in  company  epidemics. 
When  such  is  the  case,  ventilation  is  at  fault,  and  it  will  usually  be 
found  that  the  men,  for  the  sake  of  warmth,  have  stopped  up  the  air 
inlets.  Such  throat  affections  are  often  quite  severe  and  prostrating 
and  may  even  resemble  diphtheria  at  fu'st.  They  are  not  usually  due 
to  any  one  specific  germ,  but  rather  to  one  or  more  varieties  of  ordi- 
narily harmless  bacteria  residing  in  the  tliroat,  which  have  taken  on 
virulent  properties  by  reason  of  the  lowered  vitahty  of  the  tissues  due 
to  bad  air.  Tlie  sick  should  be  isolated  promptly  and  the  tendency 
on  the  part  of  fresh-air  cowards  to  plug  up  ventilation  shafts  in  cold 
weather  must  be  appreciated  and  combated. 

INFLUENZA. 

Influenza,  commonly  known  as  "the  grip,"  occurs  in  epidemic 
waves  which  affect  the  civilian  population  equally  with  the  military, 
but  as  this  is  clearly  infectious,  being  due  to  a  weU-knoAVu  bacillus, 


MILITARY   HYGIENE.  27 

and  is  transmitted  chiefly  if  not  wholly  by  contact  with  the  sick, 
such  contact  should  be  avoided  as  far  as  possible.  Tlie  influenzal 
bacillus  prefers  to  attack  the  respiratory  system,  but  may  affect  the 
digestive  tract  or  the  membranes  surrounchng  the  brain  and  spinal 
cord  as  pneumonia,  meningitis,  and  ear  suppurations  are  not  unusual. 
Marked  'depression  of  spirits  is  a  frequent  accompaniment.  Many 
people  are  cripples  in  health  for  years  after  an  attack. 

COLDS. 

Though  seldom  serious  in  symptoms  or  results,  common  colds  are 
so  frequent  and  temporarily  disabhng  that  they  deserve  mention 
here.  Many  of  them  are  undoubtedly  "catcliing, "  and  persons 
suffering  from  them  should  take  pains  to  avoid  close  contact  with 
others.  A  large  percentage  of  cases  is  due  to  overcrowding  and 
faulty  ventilation  in  barracks.  Other  causes  are  wet  feet  and  chilling 
following  overheating  of  the  body's  surface. 

MEASLES. 

We  are  apt  to  underrate  the  importance  of  this  highly  contagious 
disease,  which,  in  time  of  war,  when  new  levies  of  troops  are  brought 
together,  becomes  a  really  serious  condition.  City-bred  recruits  have 
usuaUy  had  an  attack  in  childhood,  but  those  from  country  districts 
very  hkely  have  not  encountered  the  infection.  The  disease  is  much 
more  severe  in  its  effects  upon  adults  than  upon  children.  In  the 
Union  Army  during  the  Civil  War  there  were  76,000  cases,  with  more 
than  5,000  deaths.  Among  the  Confederates  whole  brigades  were 
temporarily  disbanded  on  this  account  in  the  early  part  of  the  war. 
No  means  of  prevention  other  than  isolation  of  the  sick  and  their 
attendants  are  at  present  known.  Measles  is  due  to  a  virus  whose 
exact  nature  is  as  yet  unrecognized. 

MUMPS. 

• 

Mumps  is  also  a  contagious  disease,  and,  like  measles,  causes  much 
disabihty  among  newly  raised  troops.  It  is  not  so  serious  in  its 
results  as  measles,  but  is  a  painful  and  disabhng  affection,  especially 
when,  as  frequently  happens,  it  attacks  the  testicles.  Its  ordinary 
characteristic  is  an  inflammation  of  the  sahvary  glands  located  in  the 
neck  near  the  angle  of  the  jaw.' 

CEREBROSPINAL  FEVER. 

Cerebrospinal  fever  (meningitis)  occurs  with  considerable  fre- 
quency at  recruiting  depots,  on  transports,  and  in  camps.  Luckily, 
though  many  inhale  the  micrococcus  which  is  its  cause,  but  few  are 
susceptible  to  the  disease.  Direct  contact  is  responsible  for  the 
transference  of  the  infection  and  "carriers"  play  a  large  part  in  its 


28  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

spread.  It  is  a  very  deadly  disease  unless  antimeningitic  serum  is 
used  promptly.  Early  recognition  of  its  presence  in  the  command, 
rigid  isolation  of  the  sick  and  of  such  carriers  as  can  be  located,  with 
disinfection  of  all  cUscharges  from  their  throats  and  noses,  are  the 
essentials  in  its  prevention. 

SCARLATINA. 

Scarlatina  (scarlet fever),  though  a  highly  contagious  and  dangerous 
disease,  fortunately  attacks  adults  but  seldom,  so  does  not  need  ex- 
tended discussion  in  this  treatise,  but  a  case  of  sore  throat,  associated 
Avith  a  brilliant  eruption  on  the  skin,  should  be  regarded  as  suspicious 
of  this  disease  and  immediately  isolated. 

DIPHTHERIA. 

Diphtheria,  another  very  contagious  and  serious  affection,  is  far 
less  feared  since  the  discovery  of  its  antitoxin.  This  substance  has 
great  value  in  the  prevention  of  the  disease  as  well  as  in  its  cure.  It 
is  given  hypodermically  to  all  persons  exposed  to  the  infection,  as 
well  as  to  the  sick  man. 

SMALLPOX. 

Smallpox,  the  disease  most  dreaded  by  our  forefathers  because  of 
its  repulsiveness,  its  mortality,  and  its  disfigm-ing  effects,  has  been 
robbed  of  its  terrors  by  the  wonderful  protection  afforded  by  vacci- 
nation, but  if  the  antivaccinationists  had  then-  way  this  loathsome 
pest  would  reappear,  deadly  as  ever,  since  it  is  kept  alive  in  many 
communities  by  those  who  evade  the  means  of  prevention. 

Varioloid  is  simply  a  mild  attack  of  smallpox. 

HOOKWORM  DISEASE. 

Hookworm  disease  has  recently  been  shown  to  be  of  great  eco- 
nomic importance  in  Porto  Rico  and  our  South.  Curiously  enough, 
the  animal  source  of  this  affection,  though  its  home  is  the  human 
intestine,  makes  its  way  into  the  body  of  the  person  attacked  through 
the  skin  and  not  by  way  of  the  mouth.  The  eggs  are  passed  out  with 
the  feces  and  the  larvae — which  constitute  the  infective  form — hatch 
outside  the  body.  The  measures  of  prevention,  therefore,  consist  of 
two  things,  namely,  the  proper  disposal  of  excreta  and  the  wearing  of 

shoes. 

DENGUE. 

Dengue,  better  Imown  as  "breakbone  fever,"  is  a  disease  which 
causes  much  sicloiess  among  our  people  in  the  Philippines,  but  which, 
fortunately,  does  not  termmate  fatally.  In  common  with  malaria 
and  yellow  fever,  it  is  transmitted  by  the  bite  of  a  mosquito,  so 
measures  directed  against  this  pest  receive  an  additional  argument. 


MILITARY    HYGIENE.  29 

YELLOW  FEVER. 

Thanks  to  the  late  and  deeply  lamented  Maj.  Walter  Reed,  of  our 
Army  Medical  Corps,  who  demonstrated  the  fact  that  yellow  fever  is 
transmitted  by  the  bite  of  a  certain  mosquito  only,  we  have  suc- 
ceeded absolutel)^  in  eradicating  this  terrible  disease  from  Cuba  and 
Panama,  wliere  for  centm'ies  it  had  been  prevalent.  This  has  been 
accomplished  by  antiraosquito  measures  alone.  The  insect  con- 
cerned in  the  transmission  of  this  disease  is  known  as  the  stegomyia 
calopus  or  ' '  tiger  mosquito,"  the  latter  name  resulting  from  its  striped 
appearance,  by  which  it  may  be  recognized.  It  is  peculiar  in  the 
fact  that  it  bites  chiefly  in  the  afternoon.  It  is  a  house  mosquito, 
residing  in  or  near  dwellings,  and,  since  it  finds  favorable  breeding 
conditions  in  water  tanks  of  ships,  it  is  often  carried  about  the  world 
in  this  way.  Its  larva,  like  that  of  the  culex,  floats  head  downward 
in  the  water. 

CHOLERA. 

Cholera,  whose  normal  home  is  the  Tropics,  is  by  no  means  con- 
fined to  warm  chmates,  but  is  frequently  brought  to  our  own  shores. 
Since  we  know  its  cause  (the  "comma"  bacillus)  and  the  fact  that 
the  measures  for  its  control  are  similar  to  those  for  typhoid  fever, 
we  do  not  fear  that  it  will  affect  a  lodgment  in  the  United  States. 
Cholera  has  given  us  much  trouble  in  the  Phihppines,  but  even  there, 
where  sanitary  measures  are  carried  out  with  greater  difficulty,  its 
invasions  have  been  met  and  checked. 

TYPHUS  FEVER. 

Typhus  fever,  the  "febris  belhca"  of  older  writers,  has  been  the 
scourge  of  armies.  Dm-ing  the  Crimean  War  it  caused  more  deaths 
than  all  other  diseases  combined.  AU  of  you  know  what  havoc  it 
has  played  in  Servia.  The  great  Von  der  Goltz,  of  whom  you  will 
hear  more  about  in  the  near  future,  recently  died  with  typhus.  As 
it  is  quite  prevalent  m  Mexico  it  is  of  great  importance  for  you  to 
know  that  vermin  transmit  the  disease  from  one  person  to  another. 
Tlie  destruction  of  vermin  will  mpe  out  an  epidemic. 

PLAGUE. 

Plague,  the  "black  plague"  of  the  Middle  Ages,  estabhshes  itself 
independently  of  chmate  wherever  it  finds  favorable  conditions.  It 
has  been  demonstrated  that  rats  are  even  more  liable  to  this  disease 
than  man,  and  it  is  well  estabhshed  that  infection  is  usually  incurred 
through  the  bite  of  the  rat  flea,  which  after  the  death  of  its  normal 
host,  foi-sakes  the  latter  and  attacks  man.  Rats  should,  therefore, 
be  rentlessly  pm-sued,  their  haunts  made  inaccessible  to  them,  and 
opportunities  for  obtaining  food  cut  off.     Cousnis  of  the  rat — such 


30  MILITARY   SANITATIOISr   AND   SANITARY   SERVICE. 

as  the  prairie  dog  of  our  Western  plains  and  the  ground  squirrel 
(tarbagan)  of  California  and  Manchuria — are  subject  to  the  disease 
and  may  be  agents  in  its  transmission.  In  some  epidemics  a  very 
deadly  form  ("pneumonic"  plague)  attacks  the  lungs.  Here  the 
germ  is  transmitted  by  breathing  and  the  flea  is  not  a  factor. 

BERffiERI. 

Beriberi  is  of  interest  and  importance  for  the  reason  that  it  has 
attacked  many  of  our  PhiHpino  scouts.  No  perfectly  authenticated 
instance  of  its  occurrence  in  an  American  soldier  is  on  record.  This 
does  not  mean  that  they  are  immune,  but  rather  that  their  food 
contains  the  essential  preventive  substances.  Rice-eating  peoples 
are  most  often  affected,  and  it  has  been  found  that  some  necessary 
food  substance  resident  in  the  husk  of  the  grain  has  been  removed 
in  the  polishing  process  to  which  the  higher  grades  of  rice  has  been 
subjected.  By  substituting  an  " undermilled  "  rice  for  the  pohshed 
varieties  this  disease  has  been  entirely  controlled  among  the  scouts, 
and  its  incidence  much  lessened  among  the  Filipinos  generally. 
This  is  the  latest  instance  of  the  beneficent  effects  upon  the  health 
of  the  native  populations  of  the  occupation  of  tropical  lands  by  the 
American  Army. 

SCURVY. 

Scurvy  is  a  disease  resulting  from  scant  or  improper  diet  and  was 
formerly  common  among  armies  and  navies.  It  is  now  but  seldom 
encountered,  although  beleagured  garrisons  (as  the  Russians  in  Port 
Arthur)  and  remote  detachments  (as  in  Alaska)  are  sometimes 
affected.  Its  chief  causative  factor  is  the  absence  from  the  diet  of 
organic  acids  contained  in  fresh  meats  and  vegetables.  Potatoes, 
onions,  tomatoes  (raw  or  canned),  vinegar,  the  juices  of  rare  meats, 
lemon  and  hme  juice  are  preventive  and  curative. 

LEPROSY. 

Leprosy  is  mentioned  because  of  the  popular  interest  in  this 
affection  and  not  because  of  the  risks  of  contact.  Its  germ  is  feebly 
contagious  and  no  apprehension  need  be  felt  if  its  victims  are  en- 
countered. 

EFFECTS  OF  HEAT. 

Tlie  effects  of  heat  are  frequently  noted  on  the  march  in  hot 
weather.  These  effects  are  of  two  kinds,  notably  differing  in 
symptoms.  In  the  severer  type  (heat  stroke)  the  sick  man  is  imcon- 
scious,  his  face  is  scarlet,  his  pulses  throb  violently,  and  his  skin 
feels  bui-ning  hot.  In  the  other  condition  (heat  exhaustion)  the 
consciousness  is  retained,  but  the  man  feols  exhausted,  his  face  is  pale, 
his  heart  beats  feebly,  and  his  skin  is  cold  and  clammy.     Heat  stroke 


MILITARY   HYGIENE.  31 

is  most  apt  to  occur  when  the  air  is  not  only  very  warm  but  is  sur- 
charged witli  moisture  as  well.  Evaporation  from  tlie  skin  is  inter- 
fered with,  and  as  such  evaporation  is  an  important  means  whereby 
excess  heat  is  withdrawn  from  the  body,  the  temperature  may  rise 
to  a  dangerous  degree.  These  heat  effects  can  largely  bo  avoided 
by  timing  the  march,  when  possible,  to  take  place  during  the  rela- 
tively cooler  parts  of  the  day.  The  head  covering  should  have  a 
roomy  air  space  and  the  crown  should  contain  some  light,  moist 
object,  as  a  wet  sponge  or  handkerchief  or  green  leaves.  Water 
shoidd  be  sparingly  drunk  on  the  march;  the  man  who  empties  his 
canteen  between  halts  is  most  often  the  man  who  is  overcome  by  heat. 

SKIN  ERUPTIONS. 

Skin  eruptions  are  very  common  in  campaign,  for  the  reason  that 
men  can  not  or  do  not  keep  their  persons  and  clothing  in  a  sufficiently 
cleanly  state.  The  affections  which  occur  most  often  are  those  due 
to  the  presence  of  small  animal  parasites.  Of  these,  hce  are  the  most 
objectionable.  The  hirsute  parts  of  the  head  and  body  should  be 
inspected  for  the  eggs  of  these  insects,  which  are  readily  seen  as  little 
masses  attached  to  the  individual  hairs.  When  insects  or  their  eggs 
are  found,  the  man's  underclothing  should  be  boiled  and  the  affected 
parts  of  his  body  shaved  or  freely  anointed  with  mercurial  ointment. 

BLISTERED  FEET. 

Large  numbers  of  men  are  incapacitated — particularly  at  the  onset 
pf  a  campaign — by  blistered  feet.  The  two  chief  causes  of  bhsters  on 
the  feet  of  the  marching  soldier  are  bad  fitting  shoes  and  imcleanhness. 
The  feet  should  be  kept  dry  if  possible;  shoes,  when  wet,  wrinkle  and 
lose  their  shape.  To  insure  keeping  the  feet  in  good  condition,  their 
daily  washing,  after  getting  into  camp,  is  absolutely  necessary.  If 
sufficient  water  is  not  at  hand,  wipe  the  feet  carefully — especially 
between  the  toes — ^with  a  wet  rag. 

Shoes. — The  shoe  is,  at  least  for  the  infantryman,  the  most  impor- 
tant article  of  clothing.  It  is  only  after  many  years. of  experiment 
that  a  rational  marchmg  shoe  has  been  developed  for  our  service,  and 
the  urgent  necessity  for  exactness  in  the  fitting  of  each  soldier  with 
these  articles  and  for  their  proper  care,  appreciated.  Company  com- 
manders are  now  held  responsible  for  undue  injuries  to  the  feet  of  their 
men  fjom  ill-fitting  footwear.  Each  man  should  have  at  least  one 
pair,  weU  broken  in,  for  marching  use.  Men  sliould  be  instructed  in 
the  care  of  shoes  and  of  feet,  and  frequent  inspections  of  both  should 
be  made. 

Socks. — An  Infantry  soldier  should  carry  two  or  three  pairs  of 
socks,  wliich  ought  to  be  soft,  smooth,  and  imdarned.  Those  worn 
on  the  day's  march  should  be  washed  at  the  same  time  as  the  feet; 


32  MILITARY   SANITATION   AND   SANITARY    SERVICE. 

clean,  dry  socks  are  then  put  on  and  the  wet  ones  hung  up  to  dry. 
In  this  way  a  clean  pair  may  always  be  had.  A  woolen  sock  (hght  or 
heavy)  is  more  comfortable  when  marching  than  a  cotton  one,  because 
it  is  softer  and  more  yielding,  while  it  absorbs  the  perspiration  better. 
If  pei-spiration  of  feet  is  excessive,  a  thin  cotton  sock  under  one  of 
light  wool  does  well. 

Prevention  of  blisters. — To  prevent  blisters,  foot  baths  of  strong 
brine  or  alum  or  alcohol,  used  for  a  week  or  more  before  the  march, 
are  of  great  service  in  hardening  the  skin.  Many  experienced  soldiers 
of  our  Army  soap  the  feet  before  puttmg  on  their  socks.  In  the  Ger- 
man Army  socks  (or  rags,  which  many  wear  for  economy's  sake)  are 
soaked  in  grease.  An  excellent  powder,  made  up  of  starch,  soap- 
stone,  and  salicylic  acid,  is  supplied  by  our  medical  department  to 
sift  into  the  socks.  These  measures  are  used  to  diminish  the  friction 
of  the  foot  against  the  sock.  The  French  have  found  that  a  small 
strap  buckled  about  the  instep,  over  the  shoe,  diminishes  friction  and 
lessens  the  tendency  to  the  formation  of  blisters.  If  such  form  in 
spite  of  our  care,  they  must  be  opened  to  allow  the  serum  to  escape. 

Treatment. — The  opening  is  made  at  the  lowest  pouit  of  the 
blister,  with  a  clean  needle,  after  the  feet  have  been  washed.  The 
raised  skm  must  not  bo  disturbed,  but  is  to  be  dressed  with  vaseline 
or  other  ointment  and  protected  from  pressure  by  adhesive  plaster. 
Men  afflicted  with  bunions  or  corns  should  be  required  to  report 
promptly  to  the  surgeon  for  appropriate  treatment. 

CLOTHING.  , 

Purposes. — Clothing  protects  the  body  against  the  changing  con- 
ditions of  the  weather,  such  as  cold,  heat,  wind,  and  rain,  sliields  in  a 
measure  from  blows  and  bruises,  and  serves  to  adorn  the  person. 
The  materials  used  for  this  purpose  are  derived  from  a  variety  of 
sources,  animal  and  vegetable.  The  chief  substances  taken  from  the 
animal  world  are  wool,  fur,  leather,  and  skin;  from  the  vegetable 
Idngdom  we  obtain  cotton,  linen,  and  rubber,  as  well  as  a  number  of 
less  important  materials.  A  good  material  for  clothing  purposes  nmst 
meet  the  followmg  requirements : 

1.  It  must  afford  proper  protection  against  the  weather. 

2.  It  must  not  interfere  with  the  natural  f mictions  of  the  skin. 

3.  It  must  exert  no  irritating  effect  upon  the  skin. 

The  characteristics  and  merits  of  the  more  important  substances 
wiU  be  considered  briefly. 

Wool  is  midoubtedly  the  most  valuable  of  these  substances  used 
by  us.  It  has  the  merits  (a)  of  being  a  poor  heat  conductor,  tlms 
retarding  escape  of  warmth  from  the  body  and  preventing  the  thermic 
rays  of  the  sun  from  passing  freely.  Tlu-ough  its  heat  conservation 
it  is  much  warmer  than  cotton,  and  when  loosely  woven,  so  much  that 


MILITARY    ITYOIENE.  33 

air  is  entangled  in  tlie  meshes  of  the  fahric,  its  warmth  is  markedly 
increased.  This  property  makes  it  most  valualjle  in  cold  climates, 
and  even  in  hot  ones  it  is  not  altogether  undesirable.  The  olive-drab 
flannel  overshirt  has  been  found  to  be  a  very  valuable  garment  in 
tropical  field  service.  By  day  it  keeps  out  heat  and  chemical  rays, 
and  by  night  it  prevents  chiUing.  (b)  Wool  is  a  great  absorber  of 
water,  a  very  important  quality,  as  evaporation  from  the  body's  sur- 
face during  free  perspiration  is  checked  and  the  danger  of  chill  les- 
sened. Pei-spiration  passes  through  linen  and  cotton  freely  and  loss 
of  heat  is  rapid,  (c)  It  does  not  absorb  odors  readily.  A  disadvan- 
tage of  wool  is  that  its  fibers  become  smaller  and  harder  after  wash- 
ing, so  that  garments  of  which  it  is  composed  undergo  marked  shrink- 
ing and  stiffening.  This  tendency  is  minimized  by  washing  as  fol- 
lows: Plunge  garments,  one  at  a  time,  in  hot  soapsuds  and  use  gentle 
friction  to  cleanse  from  dirt.  Remove  and  rinse  out  all  soap  care- 
fully with  cold  water.  Hang  up  to  dry  without  wringing.  Stretch 
into  shape  while  drying  if  a  tendency  to  shrink  is  observed. 

Cotton  is  next  to  wool  in  value  for  purposes  of  clothing.  It  has 
these  merits:  (a)  Good  wearing  qualities;  (b)  cheapness;  (c)  non- 
sluinkage  in  washing;  (d)  coolness.  Its  demerits  are:  (a)  Rapid 
heat  conductivity;  (6)  poor  water  absorption;  (c)  free  absorption  and 
release  of  odors. 

Merino  (a  mixture  of  cotton  and  wool)  is  much  used  for  underwear. 

Linen  (flax  fiber)  conducts  heat  even  more  rapidly  than  cotton 
and  is  also  a  poor  absorbent  of  moisture,  besides  being  much  more 
expensive  than  cotton. 

Paper. — It  is  useful  to  know  that  paper  is  of  value  in  conserving 
warmth,  and  the  Japanese  have  utilized  it  in  military  clothing.  A 
paper  vest  affords  marked  protection  against  cold  winds,  while  a 
newspaper  between  blankets  adds  much  to  comfort  on  a  cold  night. 

Warmth  and  coolness. — The  warmth  or  coolness  of  clothuig  de- 
pends upon  several  factors;  these  are  material,  texture,  and  color. 
We  have  seen  that,  according  to  heat  conductivity  the  materials 
named,  in  order  of  warmth,  are  wool,  cotton,  linen.  Conversely, 
hnen  is  coolest  With  respect  to  texture,  the  more  loosely  woven 
the  material  the  warmer  the  garment.  Thus,  a  cotton  or  linen  loose 
mesh  under  shirt  is  much  superior  to  one  that  is  closely  woven.  The 
same  effect  of  warmth  may  be  produced  by  wearing  two  or  more 
thin  undergarments,  one  over  the  other,  the  advantage  resulting 
not  so  much  from  the  increased  thickness  as  from  the  layers  of 
warmed  air.  Color  is  of  importance  in  this  connection,  in  accordance 
with  its  relative  heat-absorbing  properties.  Thus,  white  absorbs 
least  heat;  black,  the  most.  Black  clothes  are,  therefore,  warmest; 
98756°— 17 3 


34  MILITARY   SANITATION    AND   SANITARY    SERVICE. 

white,  coolest;  blue  is  next  to  black  for  warmth;  ohve  drab  and  khaki 
are  cooler  than  blue.  OUve  drab,  being  darker,  is  markedly  warmer 
than  kliaki. 

Socks  are  furnished  in  cotton  and  in  hght  and  heavj^  wool.  Those 
of  cotton  are  suitable  for  garrison  wear,  but  not  for  marching.  Those 
of  hght  wool  (wliich  are  really  50  per  cent  cotton)  are  used  by  the 
majority  of  our  men  on  field  service.  The  heavy  socks  of  pure  wool 
are  quite  bulky,  but  are  superior  for  marching  wear,  except  in  the 
rare  cases  in  which  they  cause  skin  irritation.  Wool  absorbs  per- 
spiration better,  stretches  better,  and  fits  more  uniformly,  so  it  is 
less  hkely  to  form  creases  and  produce  blisters,  callouses,  and  corns. 
Soclis  should  have  a  seamless  foot,  with  reinforced  toes  and  heels. 
They  should  fit  well  and  have  no  rough  thread  ends.  It  is  of  interest 
to  note  that  only  two  armies  other  than  our  own  issue  socks  to  their 
soldiers.  These  are  Great  Britain  and  Japan.  The  great  mihtary 
nations  of  the  European  Continent  expect  their  men  to  provide  them- 
selves somehow  with  these  articles,  which  by  us  are  deemed  of  such 
importance.  From  motives  of  economy  many  German  soldiers  wrap 
oil-soaked  cloths  about  their  feet  in  Heu  of  socks.  A  British  mihtary 
sanitarian  (Col.  Melville)  estimates  the  life  of  a  sock  to  be  only  60 
to  70  road  miles.  This  is  probably  a  fair  mileage  for  our  hght  wool 
sock,  but  it  is  beheved  that  the  heavy  woolen  article  will  do  con- 
siderably better.  Comfort  and  cleanliness  as  well  as  regulations  re- 
quire that  socks  shall  be  changed  and  washed  daily  on  the  march. 
It  is  well  to  remember  that  a  piece  of  soft  cloth  a  foot  square  (wool 
or  part  wool)  will -make  a  better  foot  covering  than  a  worn  out  or 
poorly  darned  sock. 

Shoes. — No  one  article  of  the  soldier's  clothing  plays  so  large  a 
part  in  his  efficiency  as  the  shoe.  Although  Army  commanders  and 
sanitarians  of  the  past  century  have  emphasized  the  importance  of 
good  footwear,  it  is  but  very  recently  that  the  mihtary  shoe  hiis 
received  scientific  study.  The  marching  ability  of  armies  is  secoiul 
to  no  other  mihtary  factor,  yet,  while  enormous  percentages  of  troo]>s 
in  campaign  have  been  incapacitated  by  injuries  to  the  feet  due  to 
shoes  badly  made,  shaped,  or  fitted,  it  has  but  lately  been  realized 
that  the  conditions  were  preventable.  A  board  of  officers  convened 
for  the  purpose  by  our  War  Department  has  recently  (1912)  rendered 
its  report  in  the  form  of  a  truly  admirable  study  of  the  foot  and  the 
shoe.  A  number  of  important  recommendations  are  made  in  this 
report,  among  which  are:  (a)  Tlie  adoption  of  shoes  made  on  a 
rational  last  (one  developed  by  the  board);  (b)  careful  fitting  by 
company  officers  personally;  (c)  full  series  of  sizes  carried  in  stock  at 
posts;  (d)  frequent  inspections  of  feet  by  company  and  medical  ofli- 
cers.  The  War  Department  has  adopted  these  recommendations  and 
has  published  them  in  the  form  of  an  order,  in  which  occurs  the  fol- 


MILITARY   HYGIENE.  35 

lowing  sentence:  "Hereafter  an  undue  amount  of  injury  and  disabil- 
ity from  shoes  will  be  regarded  as  evidence  of  inefEciency  on  the  part 
of  the  officers  concerned  and  as  cause  for  investigation."  This  places 
the  responsibihty  where  it  belongs,  and  officers  will  do  well  to  study 
most  carefully  the  foot  and  its  coverings.  This  may  best  be  done 
by  consulting  the  work  "The  Soldier's  Foot  and  Military  Shoe,"  by 
Maj.  Munson,  Medical  Corps,  United  States  Army,  president  of  the 
Army  shoe  board  above  referred  to.  Maj.  Munson  lays  down  the 
foUo^A^ing  requirements  for  a  good  mihtary  shoe : 

(a)  It  must  be  of  good  materials  and  well  made. 

(h)  It  must  be  fairly  flexible,  with  phable  and  porous  uppers. 

(c)  The  interior  should  be  perfectly  smooth,  the  heel  broad  and 
low,  the  sole  but  moderately  thick. 

(d)  The  arch  should  be  flexible  and  without  metal  shank  or  other 
stiff  enmg. 

(e)  It  should  have  eyelets  (not  hooks)  for  fastening  and  the 
tongue  should  lie  smooth  under  the  laces. 

(/)  The  shoe  should  reach  only  a  Uttle  above  the  ankle;  it  should 
be  wide  across  the  ball  of  the  foot  and  should  have  high  toe  cap. 

(g)  It  must  be  comfortable,  neat  looking,  and  light  in  weight. 

(h)  It  must  be  easily  put  on  and  removed. 

Civilian  models. — The  styles  of  shoes  purchasable  in  the  shops 
are  practically  all  defective  in  shape  and  unsuitable  for  marching. 
The  "toothpick"  type  and  even  broad-toed  models  produce  a  forced 
outward  angling  at  the  junction  of  the  great  toe  with  the  main 
portion  of  the  foot.  This  shifts  the  axis  of  the  foot,  which  normally 
should  be  directly  to  the  front  in  marching.  Shoes  ordinarily  pur- 
chased are  too  small  for  the  wearer,  either  in  length,  in  breadth,  or  in 
both  these  dimensions.  It  must  be  remembered  that  the  soldier  is 
obhged  to  carry  a  load  of  clothing  and  eqyipment  amounting  to  at 
least  40  pounds.  Under  such  a  weight  the  foot,  ifunconfined, 
lengthens  and  broadens  to  a  surprising  degree.  This  may  amount  to 
more  than  one-half  an  inch  from  heel  to  toe  and  nearly  as  much 
across  the  ball.  It  is  thus  evident  that,  to  avoid  injury  in  march- 
ing, the  shoe  must  be  roomy  enough  to  allow  all  or  a  major  part  of 
this  normal  expansion. 

Supervision  in  fitting. — Soldiers  can  not  be  trusted  to  fit  them- 
selves with  marching  shoes,  as,  through  ignorance  or  vanity  (or, 
perhaps,  lack  of  proper  size),  tight-fitting  footwear  will  usually  be 
chosen  or  accepted.  Thus,  the  supervision  of  officers  becomes  neces- 
sary. 

How^  TO  FIT  SHOES. — Feet  are  measured  and  shoes  fitted  by  com- 
pany commanders  in  the  following  manner:  The  soldier  stands  with 
bared  foot  upon  a  small,  graduated  measuring  board,  resting  his  en- 
tire w^eight  (augmented  by  a  40-pound   burden  on  his  back)  upon 


36  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

that  foot.  The  length  of  the  expanded  foot  is  read  off  from  the  board 
and  the  circumference  around  the  ball  is  taken  by  means  of  a  tape 
applied  at  the  base  of  the  toes.  An  approximation  to  the  correct 
shoe  length  is  then  determined  by  adding  2  to  the  scale  reading. 
For  width,  the  table  of  sizes  given  in  the  annual  price  Ust  of  clothing, 
issued  bjr  the  Quartermaster  General,  should  be  consulted.  For  ex- 
ample, let  us  assume  that  a  foot  measures  6i  on  the  scale  and  has  a 
circumference  of  9J  at  the  ball.  Size  8^i  D  is  found  to  be  the  shoe 
which  should  approximate  a  fit;  if  this  is  not  quite  correct,  others 
will  be  tried  on  until  a  satisfactory  fit  is  had.  With  each  trial  the  shoe 
should  be  snugly  laced  and  the  soldier  will  throw  his  augmented 
weight  upon  the  shod  foot.  The  company  commander  personally 
verifies  the  fit,  assuring  himself  especially,  by  pressure  with  his 
hand,  that  not  less  than  two-thirds  inch  of  vacant  space  exists  in 
front  of  the  great  toe  and  that  no  undue  pressure  or  wrinkling  exists 
over  the  ball  of  the  foot. 

Breaking  in. — New  shoes  should  be  adapted  to  the  contours  of 
the  feet  by  gradual  wear  and  should  on  no  occasion  be  used  for  march- 
ing until  broken  in.  If  there  is  need  for  haste  in  the  process,  this 
may  be  accomplished  by  having  the  soldier  stand  in  water  for  a  few 
minutes  until  the  leather  is  sodden.  He  should  then  walk  about  for 
an  hour  or  so  on  a  level  surface,  lettmg  the  shoes  dry  on  his  feet.  On 
removal,  a  httle  neat's-foot  oil  should  be  rubbed  mto  the  leather  to 
prevent  hardening  and  cracking.  Shoes  may  be  waterproofed  by 
rubbing  a  considerable  amount  of  this  oil  into  the  dry  leather. 

It  is  beheved  that  with  the  adoption  of  the  new  shoe  and  its  com- 
plete supply  to  the  Army,  to  the  exclusion  of  other  styles,  our  service 
will  have  footwear  superior  to  that  of  any  other  nation.  The  average 
American  has  a  foot  rendered  abnormal  by  long  wear  of  shoes  of  bad 
shape  or  improper  size.  But,  taken  m  conjunction  with  the  over- 
sight m  fitting  and  care  of  the  feet  now  rendered  obHgatory,  we 
should  have  a  minimum  of  foot  troubles.  The  high  boots  worn  by 
German  and  Russian  foot  troops  furnish  a  striking  contrast  to  our 
own  shoes  in  appearance,  comfort,  and  efficiency.  That  men  can 
march  at  aU  in  such  clumsy,  misshapen  footwear  as  that  of  the  foreign 
nations  cited  is  surprising.  The  weight  of  such  boots  is  4  pounds, 
which  is  twice  that  of  our  shoes. 

Overshoes  are  desirable  for  garrison  wear,  but  not  usually  practi- 
ciible  in  field  service.  The  "arctic"  type  is  the  only  one  officially 
suppUed. 


LECTURE  III. 


MILITARY  HYGIENE. 

CAMP  SANITATION. 

CAMPS. 

There  is  no  subject  of  more  vital  importance  in  the  training  of  hne 
officers  than  military  hygiene.  This  applies  mth  especial  force  to  the 
uiihtaryhj'giene  of  field  service.  Why  is  this?  Because  when  troops 
arc  in  garrison  their  mode  of  life  approximates  in  hygienic  aiTange- 
ments  the  lite  of  the  better  class  of  the  civil  population.  Their 
dwelhngs  are  constructed  with  a  view  to  sanitary  requirements. 
Tlieir  exercises  and  habits  are  simiiarly  governed.  Their  sm-round- 
ings,  food  supply,  water  supply,  and  other  necessities  of  life  are  estab- 
lished, regulated,  and  constantly  watched  by  highly  speciaHzed  sani- 
tary officere.  In  garrison  the  individual  hne  officer  must  concern 
himself  v.ith  the  habits  and  personal  hygiene  of  his  men  and  the 
general  pohce  of  the  post ;  but  very  rarely  is  it  necessary  for  him  to 
concern  himself  directly  with  the  sanitary  arrangements  for  hving  in 
an  established  post.  Moreover,  in  garrison  it  is  extremely  unusual 
that  the  requirements  of  military  necessity  conflict  with  the  prime 
essentials  of  mihtary  hygiene.  The  troops  of  garrison  life  are  ordi- 
narily disciplined  men  who  have  received  training  in  sanitary  matters ; 
whereas  in  field  service  in  our  military  forces  a  line  officer  of  the 
standing  Army  is  very  frequently  placed  in  command  of  untrained 
or  insufficiently  trained  troops  of  the  Organized  Militia  or  Volunteers. 
In  the  field,  and  especially  in  active  service,  the  situation  is  completely 
reversed.  Life  in  the  field,  especially  where  very  large  bodies  of  men 
are  congregated,  offers  many  problems  in  sanitary,  as  well  as  other 
arrangements.  When  white  men  are  assembled  in  large  communities 
they  are  in  modern  life  accustomed  to  systematic  arrangements  for  good 
and  sufficient  suppfies  of  food  and  water;  for  systematic  disposal  of 
wastes  and  all  other  sanitary  apphances  of  like  character.  WTien  men 
are  suddenly  congregated  in  the  field  their  oflficers  at  once  find  them- 
selves face  to  face  with  the  elementary  problems  of  field  sanitation. 
Very  often  these  sanitary  problems  must  be  solved  by  the  line  officer 
individually.  At  times  the  requirements  of  mihtary  necessity  may 
compel  him  to  disregard  the  recommendations  made  to  him  by  his  san- 
itary officer,  even  though  he  himself  reahzes  their  full  significance. 
However,  when  we  leave  out  of  the  question  the  factor  of  military 

37 


38  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

necessity  the  vital  fact  remains  that  sanitation  in  the  field  depends 
upon  the  hne  officer  fully  as  much  if  not  more  than  upon  the  medical 
officer.  By  the  Hne  officer  I  mean  the  company  or  detachment  com- 
mander fully  as  much,  if  not  more,  than  the  regimental  or  division 
commander.  Tliis  statement  will  admit  of  much  explanation  and 
may  demand  much  evidence  for  substantiation,  which  I  have  not  the 
opportunity  to  give  here.  I  will  merely  cite  the  contrast  between  the 
mobihzation  camps  of  1898  and  1916.  In  the  former  case  the  line 
officers  very  frequently  did  not  reahze  the  importance  of  camp  sani- 
tation; in  the  latter  they  were  frequently  as  eager  for  sanitary  con- 
ditions as  the  medical  officers.  In  this  connection  I  wiU  read  the 
following  extract  from  a  press   dispatch  dated  San  Antonio,  Tex., 

November  28,  1916: 

As  a  result  of  the  scientific  methods  adopted  by  the  Medical  Corps  and  the  steps 
taken  to  insure  absolute  sanitation  in  border  camps  the  big  command  of  Regulars  and 
militia  has  set  a  new  health  record.  From  May  1  to  October  31  there  -were  only  75 
deaths  from  disease  in  the  force  of  more  than  150,000  men,  and  of  this  small  number 
only  21  deaths  were  due  to  infectious  maladies. 

Typhoid  fever  was  formerly  the  worst  scourge  of  camp,  but  it  has  no  place  among  the 
troops  along  the  Mexican  border.  From  May  1  to  October  18  only  21  cases  of  tjiDhoid 
developed  and  no  deaths  resulted  from  the  disease.  All  of  these  cases  were  among  the 
National  Guard  organizations,  where  in  some  instances  the  men  were  not  inoculated 
with  typhoid  serum  until  after  the  regiments  had  come  to  the  border.  There  was  not 
a-single  case  among  the  42,000  troops  of  the  Regular  Army  engaged  in  patrol  duty  and 
stationed  in  Mexico  with  Gen.  Pefshing's  command. 

In  Spanish-American  War  days — over  a  period  of  eight  months  in  1898 — among 
147,000  Regulars  and  Volunteers,  the  typhoid  epidemic  reached  the  enormous  total 
of  21,000  cases  and  there  were  2,192  deaths  from  the  disease. 

Why  is  it  that  administrative  officers  now  lend  a  ready  ear  to  the 
demands  of  field  sanitation  ?  This  question  is  answered  in  part  by 
the  foregoing  quotations.  It  wiU  be  emphasized  by  a  statement  of 
the  statistics  of  the  deaths  in  battle  or  deaths  as  a  result  of  battle 
wounds  and  deaths  from  disease  in  a  few  modem  wars. 

Mexican  War,  1846-47. 

american  regulars  onl-y  . 

Per  cent. 

Died  from  sickness ^^ 

Invalided  from  sickness,  additional  to  preceding 14 

Killed  in  battle  or  died  from  wounds 5 

American  Civil  War. 

Killed  in  battle  or  died  from  wounds 93,  907 

Died  of  disease 186,  216 

Thus  2  deaths  are  recorded  for  disease  to  1  for  battle  casualty. 

Crimean  War,  1854-56. 

French  forces 310,  000 

Died  from  disease ^^'  ^^ 

.Invalided 65,  000 

Battle  deaths 7,  500 


MILITARY    HYGIENE.  39 

Spanish-American  War. 

Deaths  from  battle  in  all  camps  and  fields 293 

Deaths  from  disease  in  all  camps  and  fields 3,  681 

This  is  1  death  in  battle  to  12.5  from  disease. 

War  Between  China  and  Japan,  1894-95. 

Japanese  forces  in  the  field 227, 000 

Deaths  from  battle 1,  311 

Deaths  from  disease 15, 850 

The  ratio  here  is  1  to  12. 

That  the  Japanese  were  taught  a  lesson  by  this  record  is  shown  in 
the  following  war : 

Russo-Japanese  War,  1904-5. 

Total  estimated  Japanese  strength  in  field  of  operations 700, 009 

Deaths  from  battle 58,  887 

Deaths  from  disease 27, 158 

In  the  same  war,  Havard  estimates  the  Russian  casualties  to  hare 
been  approximately  the  following: 

Deaths  from  battle 47,  608 

Deaths  from  disease 27, 830 

Thus  it  will  be  seen  that  even  in  modem  wars  untU  the  last  decade 
the  deaths  from  sickness  have  totaled  a  larger  figure  than  the  deaths 
from  battle.  The  noneffectives  from  sickness  are  an  even  more 
vital  military  factor  in  war  than  the  deaths,  because  of  the  fact  that 
in  effectives  from  sickness  always  number  many  times  more  than  the 
losses  by  death  from  sickness.  For  it  may  be  safely  assumed  that  if 
a  command  has  in  a  certain  period  200  deaths  from  disease,  its  con- 
stant noneffective  rate  from  sickness  will  be  many  times  that  number 
for  the  same  period. 

Before  proceeding  further  the  question  arises:  "What  are  the  prin- 
cipal camp  diseases  which  produce  the  frightful  mortahty  and  mor- 
bidity of  military  campaigns?"  The  question  is  pertinent,  because 
we  are  far  better  able  to  cope  with  an  enemy  known  than  one  con- 
cealed. 

In  the  European  wars  of  the  eighteenth  century  and  Napoleonic 
era  typhus  fever  was  an  ubiquitous  scourge.  This  disease  has  never 
been  absent  in  any  of  the  prolonged  wars  of  Europe  so  far  as  we  have 
record.  It  wiU  be  remembered  by  you  that  this  pestilence  has  pre- 
vailed in  epidemic  form  on  the  eastern  and  Serbian  fronts  during  the 
present  European  struggle.  The  same  disease  is  present  in  Mexico 
to-day,  and  must  be  reckoned  with  by  any  troops  who  wage  war  in 
the  southern  Republic.  Typhus  fever  must  not  be  confused  in  your 
minds  with  typhoid  fever,  which  it  resembles  in  some  respects.  One 
marked  difference  in  the  two  diseases,  and  the  only  one  which  here 


40  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

concerns  us,  is  the  method  of  transmission,  typhus  fever  being  con- 
veyed by  the  bite  of  the  body  louse,  whereas  typhoid  fever,  as  you 
well  know,  is  a  disease  ordinarily  transmitted  by  infected  water  or 
food  supphes.  This  brings  us  to  the  triad  of  cholera,  typhoid  fever, 
dj'senteries,  and  allied  camp  diarrheas,  which  are  often  termed  the 
\\^iter-borne  or  fly-borne  diseases  from  the  importance  of  these  two 
factors  in  their  causation.  In  American  miUtary  campaigns  these 
have  caused  the  greatest  number  of  losses  from  disease.  Other  dis- 
eases to  be  dreaded  in  mihtary  campaigns  on  this  continent  are  the 
mosquito-borne  malarial  fevers — yellow  fever  and  dengue.  Venereal 
and  respiratory  diseases,  while  not  especially  associated  with  camp 
hfe  in  distinction  from  garrison  life,  are  always  factors  in  the  sick  rat« 
of  armies. 

^Ye  have  briefly  discussed  the  reasons  for  the  importance  of  field 
sanitation  and  have  enumerated  a  few  of  the  diseases  which  have 
decimated  the  armies  of  all  history.     Before  passing  on  to  the  details 
of  this  subject,  I  shall  pause  to  emphasize  again  the  important  and 
responsible  role  which  the  line  officer  holds  m  relation  to  this  subject. 
The  supreme  commander  of  the  nation's  armies  who  would  permit 
his  subordinates  to  neglect  field  sanitation  of  campaigning  troops 
could  not  with  our  present  viewpoint  be  considered  a  wholly  com- 
petent commander,  no  matter  what  other  mihtary  quahfications  he 
might  possess.     In  no  less  degree  the  efficiency  of  the  division  or  regi- 
mental commander  who  would  slight  the  sanitary  care  of  his  troops 
would  be  dmiinished,  and  his  chances  of  military  success  would  be 
equally  curtailed.     Finally  the  company  or  detachment  conunander 
upon  whom,  after  all,  depends  the  execution  of  the  prune  requisites  of 
sanitation,  who  neglects  or  disregards  the  sanitary  regimen  of  his 
command,  is  morally  responsible  for  the  deaths  and  iUness  from  pre- 
ventable diseases  which  occur  among  his  men,  is  morally  responsible 
to  his  coimtry  for  the  ineff ectives  from  the  same  sources  in  his  com- 
mand, and  is  directly  and  judicially  responsible  to  his  higher  com- 
manders for  failure  to  enforce  the  weU-known  laws  of  camp  sanitation 
or  to  adopt  the  proper  and  practicable  recommendations  of  his  medical 
officers.     The  importance   of   your  future   position,   gentlemen,   as 
executive  officers  in  these  mattere  impresses  me  strongly  with  my 
duty  to  you  in  this  regard.     Do  not,  as  you  go  out  in  the  service, 
think  lightly  of  the  sanitation  of  your  command.     Do  not  neglect  it 
or  disregard  the  advice  of  your  surgeon.     Do  not  permit  petty  per- 
sonal or  official  differences  to  influence  you  in  the  matter  of  the  care 
of  your  command  and  its  protection  from  disease  and  death.     Do  not 
make  the  life  of  your  sanitary  inspector  a  burden  by  regarding  him 
as  an  iniquitous  pest  when  he  is  in  fact  performing  his  proper  mihtary 
duty.     Finally,  do  not  modify  or  shelve  or  otherwise  fail  to  take 
proper  action  on  his  sanitary  recommendations  unless  you  are  certain 


I 


MILITARY   HYGIENE.  41 

that  the  departmont  will  approve  of  your  action  in  stacking  up  your 
sanitary  knowlodgo  against  that  of  the  medical  oflicor,  or  that  the 
law  of  military  necessity  compels  you  to  disregard  his  advice,  or, 
finally,  that  his  recommendations  are  wholly  impracticable.  In  the 
last  event  you  may  save  yourself  much  difficulty  by  referring  the 
matter  to  higher  authority  with  your  indorsed  expression  of  opinion. 

|-  CAMP  SITES. 

Field  Service  Regulations  has  the  following  sanitary  requirements 
for  camp  sites  and  other  sanitary  arrangements  of  camps: 

Par.  236.  The  grounds  should  be  easily  drained,  naturally  healthful,  and  large 
enough  for  depots,  corrals,  hospitals,  etc.,  and  the  encampment  of  troops  without 
crowding,  and  with  ample  space  for  exercise  and  instruction. 

The  water  supply  should  be  excellent  and  abundant  and  not  liable  to  contamination 
from  any  source. 

Pak.  238.  Selection  of  site. — -There  is  often  little  choice  in  the  selection  of  camp 
sites  in  war.  Troops  may  have  to  camp  many  nights  on  objectionable  ground.  Never- 
theless, sanitary  considerations  are  given  all  the  weight  possible  consistent  with  the 
tactical  requirements. 

When  tactical  questions  are  not  involved,  and  especially  when  the  camp  is  to  be 
occupied  for  some  time,  great  care  is  exercised  in  selecting  the  site.  Through  no 
fault  of  their  own,  troops  occupying  an  unsanitary  site  may  suffer  greater  losses  than 
in  the  battles  of  a  long  campaign.  A  medical  officer  assists  in  the  selection  of  camp 
sites. 

The  selection  of  camp  sites  while  on  the  march  or  during  active  operations  is  governed 
by  the  following  conditions: 

1.  The  ground  should  accommodate  the  command  with  as  little  crowding  as  possible, 
be  easily  drained,  and  have  no  stagnant  water  within  300  yards. 

2.  The  water  supply  should  be  sufficient,  pure,  and  accessible. 

3.  There  should  be  good  roads  to  the  camp  and  good  interior  communication. 

4.  Wood,  grass,  forage,  and  supplies  must  be  at  hand  or  obtainable. 

Closely  cropped  turf  with  sandy  or  gravelly  subsoil  is  best;  high  banks  of  rivers  are 
suitable,  provided  no  marshes  are  near. 

In  hot  summer  months,  the  ground  selected  should  be  high,  free  from  underbrush, 
and  shaded  with  trees  if  possible. 

In  cold  weather,  ground  sloping  to  the  south,  with  woods  to  break  the  north  winds,  is 
desirable. 

Old  camp  grounds  and  the  vicinity  of  cemeteries  are  undesirable.  Marshy  ground 
and  stagnant  water  are  objectionable  on  account  of  the  damp  atmosphere  and  the 
annoyance  and  infection  from  mosquitoes.  Ground  near  the  foot  of  a  hill  range 
generally  has  a  damp  subsoil  and  remains  muddy  for  a  long  time.  Thick  forests,  dense 
vegetation,  made  ground,  alluvial  soil,  punch-bowl  depressions,  inclosed  ravines,  and 
dry  beds  of  streams  are  unfavorable. 

Camp  sites  should  be  selected  so  that  troops  of  one  unit  need  not  pass  through  the 
camp  grounds  of  another. 

As  a  protection  against  epidemics,  temporary  camp  sites  in  the  theater  of  operations 
should  be  changed  every  two  or  three  weeks. 

Par.  240.  Establishing  the  camp. — Camp  is  established  pursuant  to  the  halt 
order.  This  order  provides  for  the  outpost,  if  necessary,  and  gives  instructions  for  the 
encampment  of  the  main  body.  Wlien  practicable,  large  commands  are  encamped  by 
brigades. 


42  MILITARY    SAN^ITATION    AND   SANITARY    SERVICE. 

The  camping  ground  may  be  selected  by  the  supreme  commander,  but  in  large 
com  raands  is  generally  chosen  by  a  staff  officer  sent  forward  for  that  purpose.  This  officer, 
with  a  representative  from  each  brigade  and  regiment  and  a  medical  officer,  precedes 
the  command,  selects  the  camping  ground,  assigns  sections  thereof  to  the  larger  frac- 
tions of  the  command,  and  causes  them  to  be  conducted  to  their  respective  sections  on 
arrival.  He  also  designates  the  place  for  obtaining  drinking  and  cooking  water,  for 
watering  animals,  for  bathing,  and  for  washing  clothing,  in  the  order  named,  from 
upstream  down. 

On  the  arrival  of  the  troops,  guards  are  posted  to  enforce  proper  use  of  the  water 
supply:  the  interior  camp  guards  proceed  to  their  places,  and  after  posting  sentinels, 
pitch  their  tents.  The  remaining  troops  pitch  tents  and  secure  animals  and  equip- 
ment; kitchens  are  established  and  details  made  to  procure  fuel,  water,  forage,  etc., 
and  to  prepare  latrines  and  kitchen  pits;  if  necessary,  tents,  company  streets,  and 
picket  lines  are  ditched. 

In  the  presence  of  the  enemy,  places  of  assembly  for  the  troops  are  designated  and 
directions  given  for  their  conduct  in  case  of  attack.  Lines  of  information  are  estab- 
lished with  the  outpost. 

Par.  241.  Billeting. — Unless  the  force  is  small,  shelter  of  this  character  is  usually 
inadequate,  and  some  of  the  troops  must  use  shelter  tents  or  bivouac.  Villages  and 
large  farms  often  afford  facilities,  such  as  wells  and  forage,  which  contribute  to  the 
comfort  of  the  troops;  it  is  therefore  advantageous  to  camp  or  bivouac  near  them. 

Par.  232.  In  enemy  territory  public  and  private  buildings  may  be  used  to  shelter 
troops  and  for  other  military  purposes;  but  for  sanitary  reasons  troops  are  seldom 
quartered  in  private  buildings. 

Par.  242.  Bivouacs. — On  marches  or  in  the  presence  of  the  enemy  troops  are 
frequently  forced  to  bivouac  on  account  of  lack  of  suitable  ground  or  for  tactical 
reasons.  On  the  other  hand,  in  fine  weather,  in  midsummer,  or  in  the  dry  season  in 
the  Tropics,  the  troops  may  bivouac  from  choice. 

From  the  tactical  point  of  view,  bivouacs  are  very  convenient,  but  for  sanitary 
reasons  they  are  resorted  to,  as  a  rule,  only  when  necessary.  The  general  principles 
governing  the  selection  of  camp  sites  apply  to  bivouacs.  The  ground  should  be  dry 
and  protected  against  sun  and  wind.  Light  woods  are  nearly  always  good  sites  for 
Infantry  bivouacs,  on  account  of  the  shelter  and  material  a^^ailable. 

Par.  244.  Shelter  During  Sieges. — To  guard  against  danger  from  epidemics  in 
the  necessarily  crowded  camps  or  cantonments  of  the  besiegers,  the  most  careful  atten- 
tion is  paid  to  the  water  supply  and  sanitation. 

Par.  245.  Care  op  troops. — Lack  of  sufficient  rest  renders  troops  unfit  for  hard 
work  and  diminishes  their  power  of  resisting  disease.  Therefore  commanders  should 
secure  for  the  troops,  whenever  possible,  their  accustomed  rest. 

The  rvdes  of  sanitation  are  enforced. 

Men  should  not  lie  on  camp  ground.  In  temporary  camps  and  in  bivouac  they  raise 
their  beds  if  suitable  material,  such  as  straw,  leaves,  or  boughs,  can  be  obtained,  or  use 
their  ponchos  or  slickers.  In  cold  weather  and  when  fuel  is  plentiful  the  grousd  may 
be  warmed  by  fires,  the  men  making  their  beds  after  raking  away  the  ashes. 

When  troops  are  to  remain  in  camp  for  some  time  all  underbrush  is  cleared  away  and 
the  camp  made  as  comfortable  as  possible.  Watering  troughs,  shelter  in  cold  weather, 
and  shade  in  hot,  are  provided  for  the  animals,  if  practicable. 

In  camps  of  some  duration  guard  and  other  routine  duties  follow  closely  the  custom 
in  garrison.  The  watering,  feeding,  and  grooming  of  animals  take  place  at  regular 
hours  and  under  the  supervision  of  officers. 

The  camp  is  policed  daily  after  breakfast  and  all  refuse  matter  burned. 

Tent  walls  are  raised  and  the  bedding  and  clothing  aired  daily,  weather  permitting. 

Arms  and  personal  eciuipment  are  kept  in  the  tents  of  the  men.  In  the  Cavalry, 
horse  equipments  are  usually  kept  in  the  tents,  but  in  camps  of  some  duration  they 


MILITARY   HYGIENE.  43 

may  be  placed  on  racks  ontside  and  covered  with  slickers.  In  the  Artillerj'',  horse- 
equipments  and  harness  are  placed  on  the  poles  of  the  carriages  and  covered  with 
paulins. 

The  water  supply  is  carefully  guarded.  When  several  commands  are  encamped 
along  the  same  stream  this  matter  is  regulated  by  the  senior  officer.  If  the  stream  la 
small  the  water  supply  may  be  increased  by  building  dams.  Small  springs  may  be  dug 
out  and  lined  ^vith  stone,  brick,  or  empty  barrels.  Surface  drainage  is  kept  off  by  a 
curb  of  clay. 

When  sterilized  water  is  not  provided,  or  when  there  is  doubt  as  to  the  purity  of  the 
water,  it  is  boiled  20  minutes,  then  cooled  and  areated. 

Par.  246.  *  *  *  From  latrines  50  yards  to  nearest  occupied  tent;  but,  when  a 
smaller  camp  is  desired,  the  space  between  company  latrines  and  the  men's  tenta 
may  be  used  to  park  carriages  and  animals.  Latrine  seats  are  provided  at  the  rate  of 
one  seat  to  about  every  10  men;  shower  heads  at  one  to  every  50  to  100  men,  depending 
upon  water  pressure. 

Thus,  you  see,  the  prime  essentials  of  camp  sites  are  definitely  pre- 
scribed in  this  manual,  which  is  primarily  compiled  for  the  use  of  com- 
batant troops.  I  have  quoted  them  in  detail,  because  your  atten- 
tion is  thus  directed  to  the  fact  that  you  always  have  at  hand  a  guide 
in  these  matters;  and  further  because  you  can  not  go  far  wrong  in 
camp  sanitation  if  you  obey  these  simple  rules.  The  War  Depart- 
ment has  under  date  of  September  11,  1916,  seen  fit  to  issue  a  General 
Order  (No.  45)  governing  sanitary  regulation  of  camps.  This  order 
should  be  in  the  possession  of  every  ofiicer.  I  shall  quote  this  fre- 
quently in  the  subsequent  discussion. 

A  few  additional  remarks  will  not  be  useless  to  you.  Whenever 
you  are  required  to  select  a  camp  site,  it  is  important  to  consider 
the  conditions  in  the  neighborhood  of  the  proposed  camp.  Other 
things  being  equal  it  is  always  better  from  a  sanitary  standpoint  to 
place  a  camp  away  from  fixed  habitations  such  as  villages  or  towns 
than  in  or  near  such  places.  As  a  general  principle  also  it  is  wiser  to 
place  a  camp  above  stream  in  preference  to  downstream  from  a 
town  when  the  camp  site  is  to  be  along  a  watercourse.  If  you  are 
sent  ahead  of  a  marching  command  to  select  a  site,  do  not  regard 
your  work  as  satisfactorily  done  until  you  have  endeavored  to  ascer- 
tain some  information  concerning  prevaihng  diseases  among  the  in- 
habitants and  domestic  animals  of  the  locahty.  If  any  one  of  the 
serious  water-borne  diseases,  tyj^hoid,  cholera,  or  dysentery  is  present; 
if  typhus  fever  or  other  serious  contagious  disease  is  present;  if  a 
serious  epidemic  is  present  among  horses  or  cattle,  the  community 
should  be  avoided  even  for  a  temporary  camp  site.  In  the  instance 
of  a  temporary  camp  site  for  a  small  body  of  men  it  is  often  suffi- 
cient, when  you  have  selected  a  location  which  appears  to  meet  all 
requirements,  that  you  cause  inquiry  to  be  made  at  all  near-by 
houses,  or  to  the  village  doctor  or  some  other  weU-informod  person 
in  the  community  as  to  the  presence  of  contagious  or  communicable 
disease.     In  selecting  camp  sites  for  large  bodies  of  men,  a  medical 


44  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

officer  will  assist  his  commander  in  this  matter.     His  recommenda- 
tions should  in  all  cases  bo  given  due  consideration. 

The  following  details  are  to  be  kept  in  view  in  considering  the  de- 
sirability of  a  camp  site  from  a  hygienic  viewpoint: 

1.  The  site  must  be  sufficiently  extensive  to  accommodate  the  en- 
tire command  without  crowding.  For  a  bivouac  or  very  temporary 
camp,  this  feature  is  of  much  less  moment  than  in  camps  of  longer 
duration,  because  in  the  latter  it  is  a  well-estabHshed  law  that  the 
more  densely  men  are  concentrated,  the  more  liable  they  are  to  the 
occurrence  of  communicable  diseases.  Havard  considers  that  a 
brigade  should  be  the  maximum  for  one  camp. 

2.  The  site  should  be  high  enough  to  secure  a  dry  camp.  An  espe- 
cially desirable  site  is  a  plateau  or  ridge  with  a  gentle  slope  to  secure 
natural  drainage;  but  a  sharp  slope  from  one  camp  to  the  next  is 
most  undesirable  for  the  reason  that  the  pollution  of  one  camp  drains 
into  the  next.  In  cold  weather  a  slope  to  the  south  with  woods  or 
other  obstruction  to  protect  from  the  winds  is  desirable.  In  sum- 
mer or  in  tropical  campaigns  high  grounds,  breeze  swept,  and  prefer- 
ably shaded  by  trees  are  more  agreeable  camp  sites.  Grounds  at  the 
foot  of  a  ravine  are  subject  to  flooding  and  are  exceedingly^  unheal th- 
f ul  and  unsatisfactory. 

3.  Camps  should  not  be  placed  in  the  vicinity  of  marshes  or  stag- 
nant waters.  These  favor  the  prevalence  of  mosquitos,  v/ith  their 
attendant  mosquito-borne  diseases  as  well  as  their  constant  annoy- 
ance. These  localities  also  favor  rheumatic  affections,  tuberculosis, 
and  many  similar  affections,  A  camp  site  must  be  dry,  well  cleared, 
and  well  swept  by  the  sun  and  prevailing  breeze.  A  camp  site  wliich 
has  been  priorly  used  for  the  same  purpose  within  three  months 
should  be  avoided. 

4.  The  best  soil  for  camp  sites  is  a  gravel  or  sand-gravel  soil  which 
readily  permits  rain  water  to  sink  through  it.  On  the  contrary  a 
clay  or  clayey  soil  is  the  least  satisfactory.  The  character  of  the 
soil  and  subsoil  has  much  to  do  with  the  comfort  and  health  of  a 
permanent  camp,  and  when  there  is  opportunity  to  choose,  this 
factor  deserves  remembrance.  It  is  quite  important  that  the  ground 
water  should  not  be  nearer  the  surface  than  8  feet.  Twelve  feet  is  a 
safer  figure.  A  pure  sand  soil  is  disadvantageous  on  account  of  the 
glare,  the  constant  blowing  about  of  the  surface  sand,  and  the 
mechanical  difficulties  of  camping  in  sand. 

5.  The  presence  of  occasional  trees  and  shrubs  is  desirable  because 
of  the  protection  during  tlie  heat  of  the  day,  the  lessening  of  ground 
dampness,  and  the  restful  effect  upon  the  eyes.  Heavy  foliage  or 
imd(?rbrush  is  unhealthful  and  undesirable.  A  grass-covered  soil 
is  a  blessing  in  a  camp  and  should  be  preserved  as  long  as  possible. 


MILITARY   HYGIENE.  45 

WATER. 

Notliing  is  of  greater  importance  in  the  selection  of  a  camp  site 
than  an  edeqiiate  supply  of  potable  water. 

Wliat  is  an  adequate  supply  of  water?  Manifestly  a  temporary 
camp  does  not  demand  the  same  amount  as  a  prolonged  camp  with 
its  shower  baths,  laimdering  facihties,  and  even  disposal  of  sewage  by 
a  plumbing  system.  Again  a  mounted  command  requires  a  much 
greater  suppl}''  than  a  dismounted  one.  You  will  find  on  page  207, 
Field  Service  Regulations,  the  following  useful  data  on  daily  water 
requirements. 

Water.— Approximate  daily  requirements: 

One  gallon  per  man  on  march. 
Five  gallons  per  man  in  camp. 
Six  to  ten  gallons  per  animal  on  march  and  camp. 

(The  above  figures  apply  to  water  taken  from  streams  where 
animals  are  watered  at  the  streams  and  cooking  water  carried.  In 
estimating  the  daily  supply  for  permanent  or  semipermanent  camps, 
where  water  is  piped  to  kitchens,  bath  houses,  etc.,  the  requirements 
wiU  be  25  to  30  gallons  per  man  and  10  to  15  gallons  per  animal, 
depending  on  climatic  conditions.) 

Estimating  quantity  of  water  in  stream : 

BxDxVxlO,  800=gaUons  in  24  hours.  B=average  width, 
D=average  depth,  V=average  velocity  (all  in  feet). 

What  is  potable  water?  The  potability  of  water  supply  should 
always  be  referred  for  decision  to  a  medical  ofTicer,  when  present 
with  the  command.  In  case  of  doubt  or  suspicion  as  to  the  safety 
of  a  water  supply,  you  are  directed  by  Field  Service  Regulations  to 
require  that  the  water  supply  for  your  command  be  boiled  for  20 
minutes. 

Water  supplies  are  derived  from  three  sources — the  sky,  the 
surface  of  the  earth,  the  depths  of  the  earth.  Rain  water  properly 
collected  in  clean,  impermeable  cisterns  is  potable  and  above  sus- 
picion, but  is  rarely  available  for  even  a  small  body  of  troops.  Sur- 
face waters  from  rivers,  streams,  lakes,  and  ponds  may  be  pure  or 
contaminated  according  to  circumstances.  The  chief  factor  in  the 
matter  is  human  pollution.  A  river  or  stream  flowing  through  a 
spai-sely  inhabited  coimtry  is  usually  a  reasonably  safe  water,  pro- 
Aided  there  is  no  pollution  within  several  miles  of  camp.  A  flowing 
body  of  water  is  self-purifying  by  dilution,  by  sedimentation,  by 
effect  of  sunlight,  by  the  activities  of  animal  and  vegetable  life. 
Factors  to  be  considered  are  size  and  rate  of  flow  of  stream  and  amomit 
and  proximity  of  pollution.  A  river  or  stream  even  100  miles  bclov,'  a 
large"  community  in  which  a  waterborne  disease  is  prevalent  is  an 
unsafe  water  supply.     A  camp  site  on  a  very  large  lake,  many  miles 


46  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

removed  from  a  town,  usually  afiFords  a  safe  water  supply,  provided 
the  camp  is  not  permitted  to  pollute  its  own  water  supply.  Small 
lakes  and  ponds  in  thickly  populated  regions  or  near  human  dwellings 
are  a  dangerous  water  supply.  Springs  are  really  outcroppings  of 
subsoil  water  and  must  be  considered  with  reference  to  their  source 
and  liability  to  pollution.  This  may  often  be  approximately  de- 
termined from  the  surface  configuration;  more  accurately  by  color 
or  bacterial  tests. 

Subsoil  water  supplies  are  generally  classed  for  purposes  of  sani- 
tarians as  coming  from  deep  or  shallow  wells.  The  distinction  lies 
not  in  any  mathematical  terms,  but  in  the  fact  that  deep  wells  pass 
through  one  or  more  impermeable  layers  of  the  earth's  surface, 
whereas  shallow  wells  do  not.  As  you  probably  know,  a  layer  of 
water  is  encountered  a  few  feet  below  the  earth's  surface.  The  depth 
varies  greatly  in  different  localities  from  a  few  inches  to  many  feet. 
Similarly  the  height  of  this  gromid  water  varies  geratly  in  different 
locahties.  This  is  called  subsoil  water  or  ground  water  and  is  the 
accumulated  water  from  surface  drainage  of  whatever  description, 
which  is  thus  held  at  tliis  level  by  reason  of  a  supporting  layer  of  the 
earth's  surface  which  is  relatively  or  wholly  impermeable.  Any  well 
which  does  not  penetrate  at  least  one  impermeable  layer  must  then 
of  necessity  draw  upon  this  subsoil  or  ground  water  for  supply. 
You  will  readily  understand  then  why  it  is  that  in  thickly  populated 
communities  we  interdict  the  shallow  well.  You  will  readily  see  that 
such  water  supplies  in  thickly  populated  places  will  receive  con- 
stantly pollution  of  every  character;  and  even  in  sparsely  settled 
places  be  liable  to  sufficient  contamination  to  be  viewed  with  sus- 
picion. 

That  is  the  point  I  desire  to  emphasize.  Shallow  wells  are  always 
suspicious  water  supplies.  It  would  be  suicidal  for  large  bodies  of 
troops  to  obtain  their  water  supply  from  shallow  or  dry  wells  on  or 
very  near  a  camp  site  of  any  but  the  briefest  duration.  Small 
bodies  of  men  may  use  water  supplies  from  shallow  wells,  when  such 
have  been  carofuUy  examined,  and  sources  of  pollution  excluded.  In 
this  connection  two  phases  of  military  field  life  must  bo  considered. 
Troops  permanently  or  semipermanently  encamped  should  not  use 
shallow  wells  for  water  supplies  unless  these  supplies  are  treated  as 
suspicious  water  supplies  and  are  kept  mider  constant  medical  sur- 
veilance.  Troops  on  the  march  or  when  campaigning  may  be 
obliged  to  use  water  from  those  sources.  In  such  cases  how  would 
you,  as  an  organization  commander,  determine  the  probability  of  the 
purity  of  such  wells  ?  In  the  first  place,  you  must  examine  the  sur- 
face area  drained  directly  by  the  well  in  question.  This  area  is  a 
circle  whoso  radius  is  four  times  the  depth  of  the  well.  This  figure 
is  merley  approximate.     Contamination  from  surface  pollution  may, 


MILITARY   HYGIENE.  47 

of  course,  proceed  a  much  greater  distance.  But  in  this  special  area 
no  source  of  pollution  is  permissible.  Such  sources  may  be  privies, 
cesspools,  pigstyes,  manure  piles,  cattle  sheds,  stables,  and,  in  fact, 
any  manifest  organic  pollution.  When  you  come  to  examine  the 
wells  of  American  villages  and  agricultural  communities  by  this 
simple  test,  you  will  be  surprised  to  find  how  many  of  these  derive 
their  water  directly  from  such  filthy  sources.  The  second  test  is  the 
position  of  the  well  with  reference  to  the  slope  of  the  land,  '  Land  slope 
may  or  may  not  indicate  the  current  of  ground  water  depending  en- 
tirely upon  the  geology  of  the  locality.  On  the  other  hand,  a  well 
dug  on  the  mid  slope  of  a  hill  whose  summit  is  crowned  with  a  privy 
would  obviously  be  an  unsafe  water  supply. 

The  third  test  for  you  to  make  is  valuable  in  proportion  to  your 
energy  in  its  prosecution  and  the  intelligence  and  honesty  of  the 
response.  Make  inquiries  among  all  households  in  the  vicinity 
who  are  using  or  have  used  this  well  for  a  drinking  supply.  Wliat 
illness  have  they  had  in  the  past  two  years  ?  If  typhoid,  dysentery, 
diarrheas,  or  other  water-borne  diseases,  this  water  supply  is  higlily 
suspicious  and  must  be  boiled  before  use  for  drinking.  I  have  out- 
lined briefly  the  means  whereby  you  can  judge  rouglily  of  the  purity 
of  shallow  well-water.  Do  not  take  upon  yourself  the  responsibihty 
of  passing  upon  such  supply  if  you  have  a  medical  officer  on  whom 
to  bestow  this,  his  proper  responsibihty.  In  the  absence  of  a  medical 
adviser,  apply  the  foregoing  tests,  exercising  such  judgment  as  your 
experience  formulates.  In  case  of  doubt,  always  order  water  sup- 
plies to  be  purified.  So  doing  you  free  yoiu"  conscience  from  the 
possibility  of  having  illness  or  death  of  your  men  placed  upon  it. 
Deep  wells  penetrate  at  least  one  impermeable  layer  and  if  properly 
constructed  are  usually  safe  for  drinking.  Havard  says,  "A  well  to 
be  above  suspicion,  must  comply  to  the  following  requirements;  it 
should  traverse  the  entire  aqueous  stratum  and  extend  to  the  sub- 
jacent impervious  clay  or  rock;  it  should  be  fined  throughout  or  at 
least  above  the  water  with  a  weU-constructed  masonry  waU  vaulted 
at  top  with  manhole  in  center  and  thoroughly  cemented  inside." 
The  safest  rule  in  prolonged  camps  is  to  require  that  a  competent 
chemical  and  bacteriological  examination  of  the  water  supply  of 
troops  be  made  at  frequent  intervals. 

FOOD. 

Army  Regulations  are  now  quite  brief  in  prescribing  the  field 
ration  as  f oUows : 

The  field  ration  is  the  ration  prescribed  in  orders. by  the  commander  of  the  field 
forces.  It  consists  of  the  reserve  ration  in  whole  or  in  part,  su]:)]ilemented  by  articles 
of  food  requisitioned  or  purchased  locally,  or  shipped  from  the  rear,  provided  such 
supplements  or  substitutes  correspond  generally  with  the  component  articles  or 
substitutive  equivalents  of  the  garrison  ration. 


48  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

RESERVE    RATION. 

Ounces. 

iiacon 12 

Or  meat,  canned 16 

Hard  bread 16 

Coffee,  roasted  and  ground 1. 12 

Sugar 2. 4 

Salt 16 

I  shall  not  enter  into  an  orderly  discussion  of  the  relative  values  of 
different  articles  of  food,  but  confine  myseK  to  a  few  remarks  which 
appear  to  me  as  practicable. 

There  are  five  essential  elements  in  food  supply  as  follows: 

1.  Proteids;  examples  of  this  class  are  flesh  of  animals  and  animal  products. 

Function,  to  replace  tissue  loss. 

2.  Fats;  function,  to  produce  body  heat. 

3.  Carbohydrates;  examples — sugars,  starches,  vegetable  products. 

Function,  to  produce  energj\ 

4.  Salts  and  extractives,  obtained  chiefly  from  fruits,  vegetables,  and  flavoring 

agents. 
Function,  chemical  and  biologic  adjustment. 

5.  Water. 

All  of  these  elements  must  be  represented  in  definite  ratio  in  a 
diet  on  which  human  beings  are  to  subsist  for  any  prolonged  period. 
Failure  to  furnish  the  minimum  required  amount  of  any  one  of  these 
elements  will  result  in  disease  production.  Some  of  the  great 
scourges  of  the  world  have  resulted  from  disregard  of  this  law  of 
nature,  among  them  scurvy;  beriberi;  pellagra  (probably);  sprue 
(probably) ;  rickets.  These  are  well  recognized  disease  entities,  in 
addition  to  which  are  to  be  remembered  the  countless  less  definite 
evidences  of  mal-nutrition  seen  in  persons  who  are  deprived  of  a 
balanced  diet.  A  dietary  then  must  not  only  be  sufficient  in  amount 
but  characterized  by  sufficient  variety.  Of  the  five  elements  of  cfiet 
which  you  as  an  organization  commander  must  always  be  on  your 
guard  to  remember  in  the  company  ration,  No.  4,  listed  as  sidts  and 
extractives  and  obtainable  chiefly  from  fruits  and  green  vegetables, 
is  the  one  which  is  most  frequently  neglected  with  unfavorable 
results.  Remember,  gentlemen,  that  a  diet  containing  all  of  these 
elements  except  element  No.  4  will  not  be  made  complete  for  subsist- 
ence by  the  addition  of  canned  foods.  The  reason  of  this  is  that  the 
process  of  canning  requires  a  very  high  degree  of  heat,  which  destroys  a 
certain  element  in  the  food.  Tliis  is  called  "vitamin."  Its  pro- 
longed deprivation  is  very  probably  the  causative  agent  in  thi'ce  of 
the  world's  great  plagues;  beriberi,  pellagra,  and  sprue.  Remember 
then,  that  a  varied  diet  is  equally  as  necessary  as  a  hberal  one,  and 
that  fresh  or  dried  fruits,  and  green  vegetables,  potatoes,  and  other 
articles  containing  the  essential  salts  or  vitamines  are  necessary  for 
an  adequate  diet. 


MILITARY   HYGIENE.  49 

Concerning  the  amount  of  food  necessary  for  tlie  subsistevco  of 
your  men,  you  will  quickly  leani  when  you  begm  to  handle  a  company 
mess.  Men  marching  or  campaigning  in  a  cold  or  stimulating  climate 
may  be  safely  given  a  very  liberal  ration.  On  the  contrary,  men  in 
garrison  or  prolonged  camp  iu  a  hot  country  will  be  in  better  health 
for  a  diet  restricted  especially  in  meats  and  fats.  In  the  former  case, 
a  wise  commander  will  purchase  with  his  ration  allowance  the  greatest 
possible  amomit  of  real  food  utilizing  the  Government  straight  ration ; 
whereas  in  the  latter  he  will  cut  down  on  the  beef  and  beans  and 
purchase  more  delicate  and  less  heating  foods.  You  will  find  that 
time  devoted  to  the  conduct  of  your  company  msss  is  well  spent. 
A  well-fed  body  of  men  is  content,  willing  to  work,  and  disinclined 
to  indulge  in  drunkenness.  A  weU-fed  company  becomes  an  organi- 
zation which  enlisted  men  desire  to  join  and  stay  with.  Consequently 
it  can  build  up  a  cadre  of  good  men.  Moreover,  if  you  do  not  watch 
your  mess,  you  will  not  only  find  discontent  and  disciplinary  troubles 
but  you  will  find  financial  frauds  and  dishonesty  sooner  or  later 
among  the  men  to  whom  you  leave  the  matter.  General  Orders  45, 
1916,  has  the  following  on  foods  and  drink  in  camps: 

Food  and  drinks. — No  food,  drinks,  or  like  commodities  will  be  sold  in  camp 
except  in  the  authorized  exchanges. 

Attention  is  called  to  the  use  of  the  following  foods,  the  elimination  of  which  from 
the  messes  will  serve  to  prevent  a  variety  of  intestinal  disorders: 

(a)  Canned  milk  and  fish  opened  the  day  before.     (Fish  and  milk  poisoning.) 

(6)  Hashes  of  meats  and  potatoes  prepared  the  night  previous.  (Ptomaine  poison- 
ing of  severe  type.) 

(c)  Locally  grown  green  vegetables,  uncooked.     (Dysenteries  and  diarrhea.) 

The  field  cooking  may  be  of  any  character  from  the  individual 
cooking  of  active  campaign  to  the  comparatively  elaborate  methods 
of  permanent  camps.  At  the  present  time  the  field  range  is  the 
most  usual  means  of  field  cooking.  Time  is  lacking  for  details  con- 
cerning field  paraphernalia  for  cooking.  A  few  simple  rules  wUl 
suffice. 

1 .  Kitchens,  messes,  and  food-store  tents  must  be  located  at  oppo- 
site end  of  company  from  latrines.  (Field  Service  Regulations,  par. 
246.) 

2.  Kitchens  should  be  sheltered  in  marching  command  by  tent  fly 
and  brush  shelter  when  possible;  in  prolonged  camp  by  a  fly-proof 
shack. 

3.  Kjtchen  floors  should  be  well  tamped  and  sprinkled  before  each 
sweeping,  and  should  be  well  ditched. 

4.  Kitchens  and  all  utensils  must  be  clean  at  all  times.  Screened 
kitchen  shacks  should  have  improvised  flytraps. 

98756°— 17 4 


50  MILITARY   SAlSriTATIOlSr   AND   SANITARY   SERVICE. 

5.  All  fresh  food  should  be  covered  or  protected  from  flies,  dust,  and 
dirt  at  all  times.     Fresh  food  should  be  handled  in  a  cleanly  manner. 

This  includes  bread. 

6.  Garbage  and  other  refuse  should  not  be  collected  m  or  about  a 
kitchen.     Much,  if  not  all  of  it,  can  be  incinerated  at  once. 

7.  Men  should  not  be  permitted  to  sleep  in  kitchen  or  food-store 
tents,  nor  to  eat  in  their  sleeping  quarters. 

8.  Ice  boxes  and  drinking-water  barrels  should  not  be  sunk  in  the 
earth. 

9.  Tinned  meats  and  vegetables  should  be  rejected  if  perforated 
or  bulging  or  otherwise  evidencing  contammation. 

10.  Not  only  the  kitchen,  food-store  tent,  and  mess  tent  should 
always  be  scrupulously  clean  and  fly  free  but  the  earth  surface  around 
and  about  these  places. 

11.  Make  it  clear  to  your  mess  sergeants  and  cooks  that  you  will 
not  be  satisfied  with  anything  less  than  absolute  cleanliness  in  their 
department. 

12.  Enforce  your  views  by  frequent  personal  inspection  and  dis- 
ciplinary measures  for  neglect. 

DISPOSAL  OF  WASTES. 

Wastes  may  be  classified  as — 

1.  General  refuse. 

2.  Human  excrement. 

3.  Animal  excrement. 

4.  Kitchen  wastes. 

5.  Waste  waters  from  kitchens,  shower  baths,  etc. 

Field  Service  Regulations  provides  for  the  disposal  of  general 
refuse  as  follows :  ' '  The  camp  is  policed  daily  after  breakfast  and  all 
refuse  matter  burned." 

Field  Service  Regulations  provides  for  disposal  of  hiiman  discharges 
as  follows : 

Latrines  for  the  men  are  always  located  on  the  opposite  side  of  the  camp  from  the 
kitchens,  generally  one  for  each  company  unit  and  one  for  the  officers  of  a  battalion 
or  squadron.  They  are  so  placed  that  the  drainage  or  overflow  .can  not  pollute  the 
water  supply  or  camp  grounds. 

When  the  camp  is  for  one  night  only,  straddle  trenches  suffice.  In  camp  of  longer- 
duration,  and  when  it  is  not  possible  to  provide  latrine  boxes,  as  for  permanent  cam]7s, 
deeper  trenches  should  be  dug.  These  may  be  used  as  straddle  trenches  or  a  seat 
improA-ised.  When  open  trenches  are  used  the  excrement  must  be  kept  covered  at 
all  times  with  a  layer  of  earth.  In  more  permanent  camps  the  trenches  are  not  over 
2  feet  wide,  6  feet  deep,  and  12  feet  long,  and  suitably  screened.  Seats  with  lids  are 
provided  and  covered  to  the  ground  to  keep  flies  from  reaching  the  deposits;  urinal 
troughs  discharging  into  the  trenches  are  provided.  Each  day  the  latrine  boxes  are 
thoroughly  cleaned,  outside  by  scrul)bing  and  inside  by  applying  when  necessary  a 
coat  of  oil  or  whitewash.    The  pit  is  burned  out  daily  with  approximately  1  gallon  of 


MILITARY   HYGIENE.  51 

oil  and  15  pounds  of  straw.  When  filled  to  within  2  feet  of  the  surface  such  latrines 
are  discarded,  filled  \vith  earth,  and  their  position  marked.  All  latrinea  and  kitchen 
pits  are  filled  in  before  the  march  is  resumed.  In  permanent  camps  and  cantonments, 
urine  tubs  may  be  placed  in  the  company  street  at  night  and  emptied  after  reveille. 

Tills  paragraph  briefly  states  the  methods  commonly  employed 
in  our  service.  General  Order  45,  1916,  disposes  of  excreta  as 
follows : 

Disposal  op  excreta. — ^ Where  a  water-carriage  system  is  not  feasible,  the  Havard 
box  will  be  used  over  the  earth  latrines.  Daily  inspection  of  this  system  is  enjoined 
on  the  part  of  the  medical  officer  of  the  organization,  who  will  see  that  the  following 
plan  is  carried  out: 

(a)  The  latrine  will  be  burned  out  daily  with  crude  oil  and  hay.  (Each  burning 
1  gallon  crude  oil  and  15  pounds  of  hay  or  straw.) 

(b)  The  boxes  will  be  at  all  times  kept  fly  tight;  this  implies  closure  of  all  cracks, 
care  of  the  hinges  and  a  back  construction  so  that  the  lids  drop  automatically.  The 
latrine  seats  will  be  washed  off  twice  weekly  with  a  one  one-hiindredths  solution  of 
cresoline,  or  other  disinfectant,  and  whitewashed  inside  twice  weekly. 

(c)  When  filled  to  within  2  feet  of  the  top,  latrines  will  be  filled  with  dirt,  their 
positions  marked,  and  new  latrines  constructed. 

(d)  Where  water-carriage  system  is  in  vogue,  either  the  automatic  flush  or  trough 
system  will  be  installed. 

In  the  foregoing  order  it  is  customary  to  have  a  noncommissioned 
officer  such  as  the  noncommissioned  officer  in  charge  of  quarters 
take  a  squad  and  carry  out  the  burning  described  under  (a).  For 
the  compUance  with  requirement  (b)  it  is  an  excellent  plan  to  require 
the  company  artificer  to  visit  the  company  latrine  and  daily  repair 
defects. 

Animal  excreta  is  always  a  difficult  problem  especially  in  a  large 
camp.  Only  the  highest  discipfine,  and  constant  labor  will  dispose 
of  the  mass  of  manure  and  picket  line  refuse.  The  reason  that  its 
destruction  is  so  imperative  fies  in  the  fact  that  manure  is  the  natural 
breeding  place  for  flies.  It  is  estimated  that  90  per  cent  of  ffies  breed 
in  manure  and  horse  di'oppings.  The  complete  process  requires 
about  10  days.  The  fly  larvae  burrow  into  the  depths  of  the  manure 
or  the  damp  earth  beneath  until  maturity  is  reached,  so  that  an 
apparently  harmless  manure  pile  niay  harbor  millions  of  flies.  The 
fly  you  must  remember  is  just  as  much  to  be  regarded  as  a  danger 
as  the  enemy's  buUet,  and  may  kiU  off  your  men  in  much  greater 
number. 

General  Order  45  directs  as  foUows: 

Disposal  of  manure  and  care  of  picket  lines. — All  manure  will  be  hauled  to 
the  camp  dump.  Picket  lines  will  be  kept  broom  swept,  and  all  manure  and  straw 
hauled  off  daily.  A  weekly  incineration  of  the  picket  lines  will  be  accomplished 
with  crude  oil  at  the  rate  of  10  gallons  to  each  line.  Crude  oil  may  be  obtained  from 
the  Quartermaster  Corps  on  usual  requisition. 

The  foregoing  paragraph  merely  transfers  the  manure  and  with 
it  the  responsibiUty  for  its  disposition  to  another  place,  e.  g.  the  camp 
dump.     A  camp  dump  must  be  at  least  1  mile  from  camp,  and  in 


52  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

the  opposite  direction  from  prevailing  winds  when  there  are  such. 
At  the  camp  dump,  manure  may  be  disposed  of  by  burning  in  a 
huge  improvised  incinerator;  or  by  spreading  out  in  this  layers  for 
drying.  The  first  way  requires  much  constant  labor,  some  fuel,  and 
the  highest  disciphne,  especially  in  large  commands.  The  second  way 
requires  labor,  disciphne,  and  constant  official  supervision,  so  much 
so  as  to  also  prohibit  complete  success.  Those  of  your  number  who 
may  have  ever  attempted  to  govern  fatigue  parties  distributing 
manure  in  a  thin  layer  over  the  earth's  surface  wiU  readily  visuahze 
the  difhculty  of  so  governing  the  same  work  for  a  division.  One  or 
the  other  of  these  ways  may  be  successful  with  a  small  body  of 
troops.  The  very  best  way  for  a  large  command  such  as  a  brigade 
of  mounted  troops  or  an  Infantry  division  is  by  arrangement  with 
some  commercial  parties  to  haul  away  by  train  or  otherwise  the 
entire  supply  each  day.  If  this  can  not  be  done,  the  best  way  is  to 
have  the  dump  at  least  two  miles  from  any  part  of  the  camp.  Fhes 
rarely  travel  so  far  unless  carried  by  high  winds.  Carcasses  of  dead 
animals  should  be  carted  to  a  spot  selected  by  a  sanitary  officer  and 
there  burned  or  buried.  The  latter  is  usually  the  more  practical 
plan. 

General  Order  45  prescribes  the  disposition  of  kitchen  wastes,  as 

follows : 

Disposal  of  garbage. — For  detaclunents  or  companies  in  camps,  or  in  isolated 
location  where  other  means  are  not  available,  the  incinerator  will  be  installed. 

If  wood  is  plentiful  and  medium-sized  stones  can  be  obtained,  both  liquid  and 
solid  refuse  can  be  disposed  of  by  using  incinerators  improvised  for  each  company  aa 
follows: 

A  pit  is  dug  about  5  feet  long,  2|  feet  wide,  and  6  inches  deep  at  one  end  and  12 
inches  at  the  other.  The  excavated  earth  is  banked  around  the  pit  and  the  latter  is 
then  filled  with  stones  on  which  a  fire  is  built.  When  the  stones  have  become  heated 
liquid  refuse  is  poured  into  the  pit  (shallow  end),  where  it  gradually  evaporates;  solid 
matter  is  burned  on  the  fire. 

The  efficiency  of  this  type  of  incinerator  depends  largely  upon  the  fact  that  porous 
earth  absorbs  a  A'ery  large  part  of  the  liquid  slops,  but  is  not  considered  practicable 
to  destroy  the  usual  accumulation  of  slops  every  day  without  using  an  extravagant 
amount  of  fuel. 

A  type  of  incinerator  ha\'ing  a  fire  bed  of  rock  1  foot  deep  will  not  permit  the  heat 
from  the  fire  to  penetrate  beyond  that  depth.  The  rock  wall  on  three  sides  of  the 
fire  bed  absorbs  much  heat  that  otherwise  might  l)e  dissipated  into  space,'  which 
increases  the  evaporating  capacity  of  the  incinerator  enormously,  and  requkes  a 
comparatively  very  small  amount  of  fuel.  Incinerators  built  of  large  rocks  are  con- 
sidered to  be  most  efficient. 

About  one-sixth  of  a  cord  of  wood  per  day  per  company  is  considered  more  than 
euflicient  for  the  destruction  of  all  slops  and  garbage  if  ordinary  care  and  attention 
are  given  the  incinerator.  Liquid  slops  should  be  evaporated  by  being  poured  slowly 
along  the  vertical  walls  of  the  incinerator,  not  u]wn  the  fire  bed.  and  the  solid  garbage 
should  be  placed  on  top  of  the  fuel.  It  has  been  determined  that  a  skilled  attendant 
can  destroy  100  gallons  of  liquids  and  23  cubic  feet  of  solid  garbage  in  about  12  hours 
by  using  one-sixth  of  a  cord  of  wood. 


\ 


MILITARY    HYGIENE.  53 

Where  roclc  is  not  available,  material  (brick  340,  lime  three-fourths  bagi  will  be 
obtained  on  requisition  from  the  ([uartermaster.  Whore  disposal  in  a  sanitary  way 
can  be  made  l)y  means  oi  carts,  the  garliage  can  may  be  used.  The  cans  will  l.e 
thoroughly  cleaned,  scalded,  and  coated  with  crude  petroleum  after  emptying. 

KiTCHKNS  AND  MESS  ROOJis. — Kitchens  and  mess  rooms  will  be  securely  screened 
and  an  eflicient  fly  trap  provided  for  catching  such  flies  as  gain  entrance  thereto. 
An  effective  fly  trap  consisting  of  a  light  wooden  frame  covered  with  wire  gauze,  extend- 
ing to  about  one-eighth  of  an  inch  of  the  floor  of  the  trap,  is  readily  constructed .  It  has 
been  found  that  sweetened  water  slightly  acidulated  with  vinegar  is  an  excellent  bait. 

Ice  boxes  installed  will  be  inspected  daily  and  drip  pans  emptied  and  scalded  out. 

Garbage  cans  will  be  kept  on  wooden  racks  and  elevated  from  the  ground  and  cans 
burned  out  daily  with  oU  to  prevent  fouling,  and  kept  clean  outside  with  a  coat  of 
whitewash. 

There  are,  briefly,  three  ways  of  disposing  of  kitchen  garbage — - 
burning,  carting  off,  and  burying.  In  a  general  way  their  relative 
sanitary  value  is  as  in  the  order  named.  Sometimes  two  methods 
maybe  combined ;  thus,  for  example :  Solids  burned,  liquids  carted  off  or 
burned.  The  principle  involved  is  to  leave  no  organic  refuse  in  or  about 
camp  to  pollute  water  or  food  supplies  or  harbor  and  breed  flies. 

Waste  waters  from  shower  baths  must  be  carried  off  by  natural 
or  improvised  watercourse  so  as  not  to  be  a  source  of  mosquito 
breeding  or  a  nuisance  to  a  camp. 

SANITARY  APPLIANCES. 

THE    LYSTER    WATER    BAG. 

Hygiene  of  the  march. — A  few  remarks  must  suffice.  The  health 
as  weU  as  the  comfort  of  marching  commands  is  influenced  b}^  the 
manner  in  which  its  details  are  arranged.  A  commander  should 
consider  these  when  military  necessity  does  not  ride  otherwise. 
When  a  prolonged  march  extendmg  over  many  days  is  undertaken, 
especially  by  a  command  not  inured  to  marching,  it  is  wise  to  begin 
the  journey  by  short  daily  marches,  gradually  working  the  men  up 
to  longer  marches.  In  this  way  the  men  gradually  harden  up,  their 
feet  toughen,  and  by  the  end  of  a  week  they  are  fit  for  the  longer  hikes. 
He  who  gives  very  long  hard  marches  on  the  first  three  days  will 
not  hasten  the  ultimate  time  of  arrival  nor  bring  an  equal  number  of 
fit  men  to  the  goal.  This  rule  applies  to  Regular  troops  as  well  as 
others.  An  average  day's  march  for  commands  not  greater  than  a 
brigade  is  for  foot  troops  15  miles,  mounted  troops  20  to  25  miles. 
For  divisions  or  larger  bodies  the  journey  must  be  cut  down  20  per 
cent.  Troops  hardened  or  spurred  by  necessity  may,  of  course,  cover 
much  more  territory.  Remember  that  a  command  that  is  soft  may 
much  more  readily  march  20  miles  on  one  day  than  45  miles  in  three 
days;  in  other  words,  the  fatigue  is  cumulative  for  unseasoned  men, 
because  they  do  not  recover  from  one  day  of  fatigue  when  the  next 
begins. 

The  time  selected  for  marching  has  appreciable  effect  upon  physical 
condition  of  men  and  animals.  Night  marches  or  marches  beginning 
before  daybreak  depress  the  spirits  of  men  and  the  vitafity  of  men 


54  MILITARY   SANITATION"   AND   SANITARY    SERVICE. 

and  animals.  Especially  is  it  hard  on  animals  to  march  before  they 
have  had  their  food  in  quiet  and  at  the  customary  time.  In  very 
hot  places,  however,  marches  are  best  conducted  either  in  the  early 
morning  hours  or  late  afternoon  and  evening.  When  a  day's  march 
begun  in  the  early  forenoon  can  not  be  concluded  by  1  p.  m.  it  is 
wiser  to  break  its  fatigue  by  a  halt  and  Hght  lunch  shortly  before 
noon.  Similarly,  all-night  marches  should  be  broken  about  mid- 
night by  a  hght  meal.  Customarily  men  march  50  minutes  and 
rest  10  in  the  hour,  thus  covering  about  2h  miles  each  hour.  A 
faster  rate  is  more  than  proportionally  wearisome.  It  is  wise  to 
march  methodically  by  the  watch.  The  leading  troops  march  more 
easily  than  the  tail  of  the  column.  Therefore,  in  long  marches  each 
unit  should  have  its  turn  as  the  leading  element.  At  the  first  halt 
on  the  day's  march  a  period  of  20  minutes  is  usually  given  men  to 
relieve  themselves,  readjust  packs,  or  otherwise  get  in  marching  trim. 

Marching  troops  can  eat  and  digest  most  anything,  so  that  no 
special  sanitary  rules  apply  to  troops  in  this  status.  A  moderate 
morning  meal  eaten  leisurely  at  least  one  half  an  hour  before  taking 
the  road  is  the  best  provision  for  the  coming  journey.  The  discipline 
of  a  command  is  well  gauged  by  its  conduct  respecting  water  drinking 
on  the  march.  It  is  an  excellent  rule  for  a  company  conoLmander  to 
require  his  men  to  start  the  day's  march  with  a  canteen  filled  with 
water,  and  with  a  clear  understanding  that  none  shall  have  further 
supply  until  at  least  one-half  hour  after  concluding  the  day's  march. 
The  only  exception  is  the  march  in  excassively  hot  weather,  when  a 
greater  water  supply  must  be  provided.  This  should  either  be  trans- 
ported with  the  command  or  taken  from  sources  examined  or  ap- 
proved by  the  commanding  ofiicer.  Men  should  never  be  allowed  to 
break  ranks  and  forage  for  water  except  in  circumstances  of  extraor- 
dinary necessity.  This  rule  should  be  enforced  for  disciphne  and 
training  as  well  as  health.  The  cardinal  rules  for  a  snapshot  judg- 
ment of  water  supphes  have  been  already  recited.  If  you  have  a 
medical  officer  along,  put  him  on  the  trail  of  the  water  supply  as  soon 
as  you  near  the  place  of  noon  or  evening  halt.  If  not,  exercise  yoiu- 
owTi  judgment,  remembering  the  instructions  in  Field  Service  Regu- 
lations concerning  the  boihng  of  suspicious  waters,  and  the  protection 
of  your  water  supply  by  guards. 

The  care  of  the  feet  of  your  men  is  extremely  important.  It 
should  have  begun  long  prior  to  a  march  by  personal  supervision  of 
the  shoeing  of  your  men ;  by  personal  bimonthly  inspection  of  yoiu* 
men's  feet;  by  inspection  of  the  shoes  and  socks  of  your  men  before 
the  march;  and  by  the  hardening  and  seasoning  of  yom*  men  by  prac- 
tice hikes.  These  are  all  prescribed  by  War  Department  orders,  and 
if  their  provisions  have  been  inteUigently  and  faithfully  executed 
you  will  have  little  or  no  trouble  on  the  march.  But  if  you  have 
neglected  them,  your  men  will  suffer,  and  you  may  have  the  mortifi- 


MILITARY   HYGIENE. 


55 


cation  of  seeing  your  company  crippled  })y  the  disability  of  footsore 
men.  Higher  commanders  now  place  the  blame  for  tliis  condition  on 
the  unit  commander.  In  order  to  lessen  the  woes  of  the  footsore, 
require  your  men  to  start  with  good  shoes  and  socks,  and  if  allowable 
with  a  pair  of  gym  shoes  or  shppers  for  resting  the  feet  after  the  day's 
march.  At  the  termination  of  a  day's  march,  men  should  bathe  their 
feet  when  practicable  in  cool  water,  dry  them,  and  apply  clean  dry 
socks,  immediately  washing  out  the  pair  worn.  Blisters  are  best 
treated  by  zinc  oxide  plaster  or  dusting  with  the  regulation  foot  pow- 
der. Prevention  is  much  simpler  and  more  satisfactory  than  cure  of 
bruised  and  blistered  feet. 

Wlien  troops  are  marching  in  an  inhabited  country  or  when  travel- 
inof  along  routes  which  will  be  traced  or  retraced  by  themselves  or 
their  comrades,  it  is  imperative  that  the  road  shaU  not  be  left  in  a 
polluted  state.  Therefore,  when  a  command  reaches  the  place  for  the 
day's  halt,  the  commander  selects  sites  for  latrines,  and  causes  these 
trenches  to  be  dug  at  once.  In  a  fly  country  a  guard  is  placed  over 
each  straddle  trench  to  compel  men  to  cover  their  deposit  with  earth. 
Before  resuming  the  march,  the  site  of  the  bivouac  is  properly  policed. 
This  constitutes  the  ''good  manners"  of  an  Army. 


S  MO  'Z  AmbJjfK^  " 


\A.  \   QMedrcol  5<jpply 

^<'~  t  Suraecrt  Niedical  Advance  Group 
5!  *  5  S      " 


0Re5t5rahon 

^^   Pc/-yonn€/ notftKCa 


NOTE  • 

L  nes  6hoi*^  Direct 'On  of  £^acu<yt/on 


HeadqiAjrlers  Lmeof  Co 
Surgeon  Medrcal   BaseGrot/p 


L..nc^.5notvU'reCT'Cn  Or  LyaCU<Jr/On  jurgeoni-ieoicar    oaiei^rut/p 

andb^  ^natPer.^.nn^,cccomp/,5hecf     ^^^^  ^  l!^- fo^SSU  + '^ <>o.. J^,^.^,^ 
Suppli^  Depot  I     I 

ZMQISCM    I — j<! 


Hosp.tol5hip  J^/^ 


LECTURE  IV. 


THE  SANITARY  SERVICE  OF  THE  MARCH  IN  CAMPAIGN. 

It  may  be  said  that  the  sanitary  service  of  the  march  should  begin 
with  the  physical  examination  of  the  recruit.  Napoleon,  the  most 
illustrious  of  all  eugenists,  is  alleged  to  have  begun  before  this,  when 
he  sent  recruiting  sergeants,  selected  for  their  mental  and  physical 
qualities,  to  the  villages  of  France,  almost  depopulated  of  fit  adult 
males  by  the  ravages  of  war.  Certainly  the  selection,  training,  cloth- 
ing, and  equipment  of  the  soldier  must  be  controlled  carefuUy,  in 
order  to  permit  efficiency  on  the  march  and  in  combat,  and  this  can 
not  be  too  painstaking  and  thorough.  Given  the  recruit  of  proper 
conformation,  as  shown  by  physical  examination,  he  should  be 
trained  physically  and  mentally  for  the  duties  which  will  be  required 
of  him.  His  clothing,  shoes,  and  equipment  must  be  furnished  and 
adjusted  in  such  a  manner  as  to  permit  freedom  of  movement,  ^^'ith- 
out  constriction  or  interference  with  organic  functions;  and  he 
must  be  instructed  and  physically  trained  by  carefully  graduated 
exercises  in  use  and  manner  of  can-iage  of  equipment,  marching,  and 
personal  and  general  hygiene.  This  training  must  not  be  excessive 
as  to  duration  in  time  of  effort  at  first,  because  the  average  Amerioan 
recruit  has  had  httle  training  in  walking  and  weight  carrying,  and 
his  physical  development  is  not  completed.  Excessive  drill  will  not 
only  retard  his  set  up  and  development,  but  may  possibly  give  a 
temporary  breakdown  in  some  part  of  the  organs  of  locomotion 
(most  frequently  in  the  feet)  and  by  reason  of  exhaustion  and  dis- 
comfort affect  his  morale  as  a  marcher. 

The  sanitary  service  on  the  march  in  campaign  concerns  itself 
with  the  institution  of  proper  sanitary  measiu-es  for  the  prevention 
of  disease,  the  care  and  evacuation  of  the  sick,  and  the  conduct  and 
administration  of  the  personnel  and  material  for  these  pm-poses  on 
the  march,  in  camp,  and  combat. 

The  attached  sanitary  troops,  before  beginning  the  march,  super- 
vise the  final  sanitation  of  the  abandoned  camp,  bivouac,  or  field, 
and  arrange  for  tho  care  and  transportation  of  the  sick  and  disabled ; 
usually  each  battalion  surgeon  with  his  imit  personnel  covering  tho 
command  to  which  he  is  attached,  under  the  supervision  of  the 
Burgeon,  who  makes  a  final  survey  of  the  situation.     The  battaUon 

56 


I 


SANITARY    SERVICE    OF    THE    MARCH    IN    CAMPAIGN.  57 

sanitary  personnel,  consistin*^  of  a  medical  ofFicer,  a  noncommissioned 
oflicer,  and  an  orderly  mounted,  and  one  or  more  litter  squads  of 
two  men  each,  march  at  the  rear  of  the  battalion  to  which  attached. 
This  position  places  the  sanitaiy  personnel  at  a  point  whore  on  the 
ordinary  march  it  will  be  able  to  obsei-ve  the  general  condition  of 
the  personnel  of  the  command  and  come  up  in  the  course  of  the 
march  to  any  fall  outs,  without  the  necessity  of  special  exertion  on 
their  part,  or  upon  the  part  of  anyone  in  going  foi-ward  to  secure 
their  services;  and  permits  obsei-vation  of  signals  from  the  front, 
should  service  be  required  in  this  direction.  This  position  at  the 
rear  of  the  battalion  leaves  the  personnel  in  position  to  cover,  with- 
out unnecessary  movement,  the  battalion  or  any  part  of  it  should 
it  deploy. 

The  medical  officer  with  the  battalion  wdll  not  at  all  times  confine 
himself  to  a  position  at  the  rear  of  the  battahon,  but  will,  from  time 
to  time,  go  forward  to  inform  himself  as  to  changes  in  march  condi- 
tions; the  condition  of  various  members  of  the  command  he  has 
imder  observation;  in  response  to  calls  for  services;  and  to  observe 
conditions  of  water  or  other  supply  on  the  route  of  march;  and  at 
halts  will  supervise  disposal  of  excrement,  wastes,  etc.  Before  the 
noon  halt,  if  there  be  such  a  halt  intended,  and  before  approach  to 
camp,  he  should  ride  forward  in  order  to  inform  himself  as  to  water, 
drainage,  terrain,  etc.,  in  order  to  give  such  assistance,  from  a  stand- 
point of  sanitation,  as  may  be  necessary. 

Cases,  sick  or  disabled,  requiring  care  or  treatment,  are  sent  with 
a  pass,  showmg  the  name,  company,  and  regiment  or  corps,  of  the 
sick  person,  to  the  medical  officer  in  the  rear.  The  medical  officer 
returns  the  pass  showing  the  disposition  of  the  case.  The  medical 
officer  should  dispose  of  tliis  case  according  to  the  conditions;  he  may 
reheve  him  of  his  pack,  if  he  be  an  mfantryman,  and  require  him  to 
march,  or  he  may  put  him  in  an  ambulance  or  any  other  transpor- 
tation, if  there  be  no  ambulance  attached  to  the  organization ;  or  he 
may  require  him  to  march  fuU  pack,  at  the  rear  of  the  organization, 
under  observation.  Wherever  a  fall-out  is  separated  from  the  or- 
ganization, he  is  given  a  diagnosis  tag,  showing  the  orders  given  him. 
The  arms  and  personal  equipment  of  a  foot  soldier  accompany  him, 
the  moimt,  saddle  equipment,  and  saber  of  a  mounted  soldier  are 
returned  to  the  troop,  usually  by  the  noncommissioned  officer,  who 
accompanies  him.     (F.  S.  K.,  343.) 

Rapidly  moving  mounted  commands  will  usually  have  no  trans- 
portation other  than  mounts  or  gmi  carriages  for  the  disabled,  in 
which  case,  the  squadron  surgeon,  must  act  m  accordance  with  the 
patient's  condition,  and  the  circumstances  of  the  march.  The  pa- 
tient may  be  required  to  foUow  the  command  at  a  walk,  he  may  be 


58  MILITARY    SANITATIOISr    AND    SANITARY    SERVICE. 

sent  back,  escorted  or  unescorted  by  a  sanitary  soldier,  with  or  with- 
out wheeled  transportation,  toward  the  main  body,  or  the  lines  of 
communication;  or  he  may  be  left,  with  or  without  an  attendant,  under 
shelter,  to  be  cared  for  by  friendly  mhabitants  or  to  be  picked  up 
by  sanitary  troops,  furnished  with  proper  transportation. 

Whatever  action  is  taken  with  regard  to  the  disposition  of  the  dis- 
abled and  their  equipment,  careful  note  and  report  must  be  made 
of  it,  m  order  that  aU  may  be  cared  and  accounted  for,  and  at  the  end 
of  the  march,  collected,  examined,  treated,  and,  if  necessary,  evacu- 
ated to  the  rear. 

Those  sanitary  troops  attached  to  separate  or  independent  bat- 
talions will  have,  in  addition  to  their  personal  equipment,  one  pack 
mule  with  aid  station  equipment,  which  wiU  accompany  the  bat- 
tahon  combat  train,  of  which  it  is  a  part.  The  sanitary  troops 
attached  to  a  regiment  are  usually  divided  for  march,  camp,  and 
combat  duties  into  the  battalion  or  squadron,  and  headquarters 
sections,  giving  to  the  regiment  of  infantry  three  battahon  and  one 
headquarters  section. 

The  headquarters  section  usually  consists  of  the  senior  medical 
officer,  the  senior  noncommissioned  officer,  one  orderly,  all  mounted, 
and  from  two  to  four  privates  in  numbers,  and  mounted  or  dis- 
mounted, in  accordance  with  the  allowance  of  men  and  animals  for 
sanitary  troops  of  the  arm  with  which  they  are  servmg.  The  senior 
medical  officer— the  surgeon — ^with  his  mounted  orderly  marches 
with  the  staff  of  the  regimental  commander,  unless  there  be  no  other 
medical  officer  with  the  regiment,  then  he  marches  in  the  rear.  He 
is  required  to  be  with  the  regimental  commander,  in  order  that  he 
may  be  available  for  consultation  with  regard  to  sanitary  matters, 
and  that  he  may  be  informed  as  to  general  and  special  situations,  as 
they  may  arise,  relating  to  various  conditions  that  might  affect  sani- 
tation and  care  of  the  troops,  and  the  handling  of  the  sanitary  troops; 
the  selection  of  camp  sites,  examination  of  water  and  food  supplies, 
disposal  of  wastes,  and  dispositions  of  the  sanitary  troops. 

The  senior  noncommissioned  officer  of  the  sanitary  troops  (head- 
quarters section)  with  the  privates  of  the  Medical  Department 
attached  to  his  section,  marches  at  the  rear  of  the  last  battalion, 
with  the  sanitary  troops  of  that  battalion,  and  has  in  his  charge  the 
pack  mule,  carrying  the  regimental  aid  station  equipment,  and  the 
ambulance,  if  the  regiment  is  part  of  a  reinforced  brigade  or  division 
of  which  ambulance  companies  are  a  component.  If  the  regiment  is 
actuig  independently,  he  will  be  in  charge  of  the  three  or  foiu'  ambu- 
lances and,  on  an-ival  at  camps,  the  wheeled  transportation,  which 
carries  the  regimental  infii-mary  or  hospital.  The  position  of  the 
headquarters  section  of  the  regimental  sanitary  personnel  at  this 
point  on   the  ordinary   march    permits  conti'ol  of  equipment  and 


SANITARY    SERVICE    OF    THE    MARCH    IN    CAMPAIGN.  59 

transportation  on  tlio  march,  and  in  case  of  deployment  leaves  this 
equipment  in  proper  position,  in  readiness  to  advance  and  establish 
where  directed.  Under  this  condition  the  vs^agons  of  the  regimental 
infii'mary  or  hospital  would  be  back  in  the  regimental  field  train. 

On  a  march  in  retreat,  in  a  brigade  or  division,  if  the  regiment  is 
not  acting  as  advance  or  rear  guard,  the  distribution  of  sanitary 
troops  is  the  same  as  given  for  the  ordinary  march. 

If  the  regiment  is  marching  alone  with  an  advance  guard  of  one 
battalion,  the  disti'ibution  is  that  of  an  ordinary  march  and  the 
battalion  sanitary  troops  will  march  with  the  reserves  of  the  battalion, 
with  possibly  one  man  with  support,  if  such  there  is.  The  formation 
will  practically  be  the  same  for  a  regiment  acting  as  advance  guard 
with  a  battalion  as  the  support — each  battalion  will  carry  its  person- 
nel as  usual,  the  surgeon  will  be  with  the  commanding  officer,  and 
the  battalion  forming  the  support  will  have  one  or  two  men  of  the 
sanitary  personnel  with  the  advance  party. 

In  a  retreat  of  a  regiment,  or  a  regiment  acting  as  a  rear  guard, 
the  reserve  will  be  reinforced  by  the  sanitary  personnel  from  the 
main  body  of  the  battalion  or  regiment,  in  order  that  the  womided 
of  the  retreating  rear  guard  may  be  rapidly  evacuated  ahead  of  the 
ti'oops.  If  ambulances  are  available,  as  in  a  regiment  acting  inde- 
pendently, it  may  be  weU  to  attach  one  to  the  tail  of  the  main  body, 
between  it  and  the  reserve  of  the  rear  guard,  leaving  the  pack  mule 
and  remaining  ambulances  to  march  with  the  leading  battalion. 

Ambulance  companies  are  divisional  sanitary  organizations,  but 
for  purposes  of  care  and  transportation  of  the  sick  and  wounded, 
may  be  attached  to  separate  brigades,  which  are  operating  away  from 
the  division.  Under  the  conditions  of  the  ordinary  march,  when 
hostile  contact  is  not  expected,  ambulance  companies  march  and 
camp  together,  with  the  exception  of  one  ambulance  company,  which 
imder  proper  orders  may  have  its  ambulances  distributed  through 
the  column,  one  to  each  regiment,  for  use  in  transportation  of  the 
disabilities  that  occur  on  the  march.  (F.  S.  R.  341.)  Under  these 
conditions  of  the  ordinary  march,  these  ambulance  companies,  not 
concerned  in  the  regimental  service  for  the  day,  march  as  do  other 
organizations ;  their  positions  ordinarily  in  the  rear  of  the  field  trains 
when  marching  as  a  unit,  with  their  field  wagons;  when  marching 
with  light  transportation  (pack  mules)  only  the  ambulance  compan- 
ies march  in  advance  of  the  field  trains. 

Under  conditions  of  untrained,  or  fatigued  pei"sonnel,  bad  weather, 
or  long  marches,  action  may  be  taken  to  increase  the  number  of  am- 
bulances temporarily  attached  to  the  regiment,  for  the  pui'poses 
of  the  march,  as  much  as  may  be  necessary.  These  ambulances  so 
distributed  to  the  regiments  are  for  use  in  transportation  of  the  disa- 
bled and  their  equipment,  and  must  not  be  diverted  to  any  other  use. 


I 


60  MILITARY    SANITATION    AND    SANITABY    SERVICE.' 

They  are  under  the  orders  of  the  director  of  ambulance  companies 
and  their  movement  will  be  controlled  by  hun,  in  carrying  out  the 
orders  of  the  surgeon  or  the  commandmg  officer.  At  the  beginning 
of  an  engagement,  or  at  the  end  of  the  march  the  distributed  ambu- 
lances will  be  assembled  by  the  orders  of  the  director,  usually  given 
through  the  company  commander.  All  disabled  sick  in  the  ambu- 
lances at  this  time  who  require  more  than  temporary  care  or  ti*ans- 
portation  will  usually  be  sent  back  by  the  regimental  sui'geon  with 
ambulances.  When  they  move  to  assemble  in  preparation  for  an 
engagement,  the  disabled  will  be  collected  at  some  central  point  in 
the  rear  for  further  evacuation,  if  on  arrival  at  camp,  at  the  probable 
site  of  the  camp  infirmary,  or  to  the  field  hospital  for  fm*ther  treat- 
ment and  evacuation  according  to  the  conditions  and  orders. 

This  arrangement  of  the  ambulance  companies  in  column  for  the 
ordinary  march,  is  to  perlnit  such  use  of  organizations  as  may  be 
necessary  for  the  transportation  of  the  disabled,  and  to  permit  rapid 
collection  of  the  disabled  on  arrival  at  camp,  without  unnecessary 
movement  of  disabled  or  transportation. 

The  ambulance  companies  whose  ambulances  are  not  distributed 
to  the  organizations  on  the  march,  are  held  in  their  position  behind 
the  field  trains,  as  they  camp  at  the  rear  of  the  center  of  the  division, 
and  ordinarily  not  more  than  one  is  concerned  in  regimental  duty. 
With  this  position,  they  do  not  become  involved  in  the  movement  of 
the  field  trains  to  their  organizations  or  on  their  return;  and  are  in 
position  to  join  the  column  for  the  next  day's  march.  .  The  details 
for  march  duty,  with  the  regiments,  will  be  made  by  the  dhector, 
ordinarily  by  roster,  and  the  positions  in  column  will  be  determined 
in  a  like  manner  by  the  director  of  ambulance  companies,  acting  as  a 
battalion  commander. 

Changes  from  the  routine  order  of  march,  will  usually  be  made  on 
recommendation  of  the  surgeon,  in  the  march  order,  according  to  the 
necessities  of  the  case.  This  position  of  the  ambulance  companies 
behind  the  field  trains,  places  them  sufficiently  far  forward  to  permit 
m  case  of  rencontre,  advance  of  the  ambulance  companies  sufficiently 
early  to  be  of  use  when  required,  and  yet  not  have  them  as  far  for- 
ward as  to  have  them  unnecessarily  involved  in  conflict. 

The  ambulance  companies  with  light  transportation,  march  at  the 
tail  of  the  combatant  column;  such  a  position  usually  is  the  result 
of  a  desire  to  have  the  more  mobile  part  of  the  organizations  ready 
for  early  use,  or  is  the  result  of  difficult  roads,  or  failure  of  heavy 
wheeled  transport;  either  condition,  if  the  ambulance  companies 
were  kept  behind  the  heavy  transportation  of  the  field  trains,  might 
possibl}'-  put  them  so  far  back  as  to  render  them  useless. 

The  usual  order  of  march  of  an  ambidance  company  is  that  of 
ordinary  comimands  of  mixed  organizations.     The  foot  troops,  the 


SANITARY    SERVICE    OF    THE    MARCH    IN    CAMPAIGN.  61 

bearer  sections  with  litters,  first,  followed  by  the  pack  mules  with  the 
dressing  station  detachment,  next  the  ambulance  detachment,  and 
lastly,  the  tlii'ee  wagons:  The  first  wagon  carries  reserve  dressings 
and  equipment  lor  the  di"essing  station,  and,  where  possible,  accom- 
panies the  di'essing  statioji  party  forward  as  a  combat  wagon. 

The  road  distance  of  an  ambulance  company  on  the  march  without 
elongation  is  280  yards;  the  road  distance  for  three  ambulance  com- 
panies with  15-yard  interspace,  870;  the  usual  distance  given  for 
four  companies  is  1,160  yards,  but  rarely  will  these  be  found  together. 
The  director  of  ambulance  companies  ordinarily  accompanies  the 
ambulance  company  in  advance  on  the  march,  such  a  position  places 
him  so  that  he  will  be  able  to  receive  messages  from  the  front  and 
rear  easily  and  yet  supervise  the  work  of  his  organizations  as  it  occurs. 
This  advanced  position  also  gives  him  an  opportmiity  to  famiharize 
himself  with  the  conditions  of  roads,  terrain,  etc.  On  ordinary 
marches,  particularly  when  the  roads  are  dusty,  the  dismomxted 
detachments  of  the  sanitary  battahon  are  frequently  marched  together 
as  a  matter  of  comfort,  followed  by  the  pack,  ambulance,  and  wagon 
detachments,  combined  in  order  of  the  companies;  such  action,  while 
removuig  the  transportation  from  immediate  control  of  the  com- 
mandmg  officer,  does  not  cause  material  delay  in  going  into  action; 
as  these  detachments  have  medical  officers  m  command,  and  objec- 
tion on  this  score  does  not  hold  good,  the  conditions  of  the  march 
are  certainly  improved  greatly. 

The  march  ui  the  presence  of  the  enemy,  where  hostile  contact  may 
be  expected,  requires  as  it  does  with  the  line  troops  a  different 
arrangement  of  the  ambulance  companies  m  the  column.  With  the 
reinforced  brigade,  the  single  ambulance  company  attached  is  moved 
up  in  advance  of  the  field  trains,  to  the  tail  of  the  column  of  com- 
batant troops,  so  that  it  will  not  be  forced  to  participate  in  the  retire- 
ment of  the  field  trains,  if  such  retirement  is  necessary,  and  that  it 
may  be  in  readiness  for  action  should  the  brigade  deploy  for  attack 
or  defense,  and  in  case  of  retreat  be  sufficiently  advanced  to  permit 
detachment  of  a  platoon  of  ambulances  and  bearers  for  duty  with 
the  rear  guard  for  the  purpose  of  expediting  the  evacuation  of  the 
wounded. 

The  distance  from  the  reserve  of  the  rear  guard  to  the  tail  of  the 
main  body  of  the  brigade  vtill  be  about  4,000  yards,  a  distance  that 
could  be  traversed  by  the  ambulance  company,  if  necessary,  while 
the  brigade  is  deploying,  if  it  were  desirable  to  bring  it  up  to  this 
pouit.  Such  action,  however,  would  not  be  contemplated  mitil  late 
in  the  action,  and  if  the  dressing  station  estabfishes  it  will  bo  well 
to  the  rear.  The  regimental  sanitary  personnel  will  be  sufficient  to 
care  for  the  woimded  mitil  the  dressing  station  can  go  into  action 
and  the  position  of  the  ambulance  company  at  the  rear  of  the  column 
is  correct  for  a  columii  of  this  size. 


62  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

With  a  brigade  in  retreat,  however,  if  the  ambulance  company 
were  marched  with  the  leading  troops  (with  the  same  4,000  yards 
from  the  reserve  of  the  rear  guard),  in  default  of  wheeled  transporta- 
tion the  wounded  resulting  from  a  general  rear  guard  action  must 
be  abandoned  or  carried  by  hand. 

If,  as  mentioned  above,  a  platoon  of  three  ambulances  be  attached 
to  the  reserve  of  the  rear  guard,  with  five  or  six  litter  squads  from 
the  bearer  detachment,  these  reinforced  by  the  regimental  sanitary 
personnel  will  be  able,  imder  ordinary  conditions,  to  evacuate  a  con- 
siderable portion  of  the  wounded  requiring  transportation. 

With  a  division  marching  in  the  presence  of  the  enemy  or  when 
hostile  contact  may  be  expected,  ambulances  will  not  be  distributed 
to  the  regiments,  but  will  be  held  with  the  ambulancte  companies. 
With  the  normal  advance  guard  of  one  brigade,  one  ambulance  com- 
pany will  be  attached  to  the  advance  guard  and  march  usually  at 
the  rear  of  the  reserve,  as  the  distance  from  the  tail  of  the  reserve 
to  the  tail  of  the  combatant  troops  of  the  main  body  wiU,  without 
elongation,  be  some  7  miles,  a  distance  too  great  to  permit  a  unit 
of  the  size  of  a  brigade  to  be  without  medical  assistance  other  than 
the  regimental  personnel  during  the  time  it  would  take  an  ambulance 
company  to  come  to  the  front.  If  a  general  action  is  imminent,  the 
advance  guard  will  be  engaged  for  a  considerable  time,  and  the  ambu- 
lance company,  equipment,  and  personnel  will  be  required  early.  If 
the  advance  must  continue,  this  equipment  will  be  required  to  take 
over  the  woimded  and  release  the  regimental  personnel,  so  that  it 
can  continue  with  its  command.  If  a  retreat  is  required,  this  organ- 
ization, well  up  to  the  scene  of  action,  offers  the  only  means  of  evacu- 
ation of  the  wounded. 

The  positions  of  the  sanitary  imits  of  a  aivision  m  retreat  are 
identical  with  those  of  a  march  formation  with  advance  guard,  ex- 
cept that  organizations  are  faced  about,  and,  if  necessity  arises  for 
delaying  actions  of  some  duration,  the  ambulance  companies  with 
the  brigade  rear  guard  may  be  reinforced  by  additional  ambulance 
and  bearer  platoons,  in  order  to  expedite  the  evacuation  of  the 
womided  of  this  force,  which  must  retreat  soon. 

Flank  guards  of  a  brigade  or  more,  when  detached  a  sulhciont 
distance  from  the  main  body  to  warrant  such  action,  should  b(^ 
furnished  a  proportional  amount  of  sanitary  assistance.  As  such  a 
command  must  keep  in  movement  consonant  with  the  movement  of 
the  main  body,  it  must  not  be  impeded  by  the  disabled,  and  th(> 
allowance  of  ambulance  company  personnel  and  equipment  should  bo 
li})eral.  The  method  of  distribution  of  sanitary  personnel  of  a  flank 
guard  on  the  march  is  that  of  a  brigade  or  division  when  hostile 
contact  is  expected. 


SANITARY    SERVICE    OF    TTTE    MARCH    IN    CAMPAIGN.  63 

The  distribution  of  the  three  ambulance  companies  on  the  march 
with  a  Cavah-y  division  conforms  to  that  of  an  Infantry  division, 
except  that  on  account  of  the  superior  mobihty  of  the  Cavalry 
division  on  marches  where  contact  may  be  expected,  it  may  be  fre- 
quently necessary  to  carry  the  packs  of  the  dressing-station  equipment 
and  bearer  detachment  in  ambulances,  leading  the  unloaded  puck 
mules  from  the  tails  of  the  ambulances  in  order  to  keep  up  with  the 
command;  the  wagon  transportation  being  directed  to  follow  at  best 
speed  consistent  with  constant  marching.  Such  an  arrangement  per- 
mits these  organizations  to  go  forward  with  all  the  speed  that  can  be 
expected  from  mule-drawn  wheel  transport.  When  getting  into 
ground  unsuitable  for  wheeled  transportation,  the  pack  mules  can  be 
reloaded  and  the  bearer  detachment  move  out  on  foot  from  the 
ambulance  head  with  light  transportation. 

The  position  of  the  field  hospitals  of  an  Infantry  division  on  an 
ordinary  march  is  at  the  rear  of  the  ambulance  companies,  which  are 
preceded  by  the  field  trains — the  director  of  the  field  hospitals  usually 
marches  with  the  most  advanced  organization.  The  duties  of  the 
field  hospitals  on  the  ordinary  march  are  limited  to  arranging  for 
estabhshment  of  sufficient  equipment  to  shelter  the  daily  increment 
of  disabled,  prior  to  evacuation.  As  these  organizations  camp, 
usually  with  the  ambulance  companies,  in  a  position  to  cover  the 
rear  of  the  center  of  the  divisional  camp,  their  place  in  the  columil 
coincides  with  this  intent  and  permits  entrance  into  the  column  the 
following  day  without  confusion. 

The  necessity  of  use  of  field  hospitals  in  action,  such  as  would  occur 
only  under  the  conditions  of  a  meeting  engagement,  does  not  require, 
and  in  fact  forbids  early  establishment;  and  the  position  of  the  field 
hospitals  in  this  column,  some  8  miles  from  the  head  of  the  main 
body,  keeps  them  well  out  of  range  of  light  artillery  fire  and  yet 
permits  arrival  in  proper  position  within  two  hours  if  necessary. 
Wliile  the  field  service  regulations  require  a  field  hospital  to  be 
located,  so  as  to  permit  early  care  of  the  sick  on  arrival  at  camp,  the 
camp  infirmary,  marching  at  the  rear  of  the  brigade,  now  provides  for 
and  can  do  this,  until  the  estabhshment  of  the  field  hospital.  Under 
conditions  where  delays  of  trains  may  occur,  a  field  hospital  may  be 
marched  at  the  tail  of  the  main  body,  in  order  to  place  it  in  position 
to  estabhsh  an  hour  and  a  quarter  earlier.  As  the  road  space  of  a 
field  hospital  company  is  only  160  yards,  such  an  arrangement  will 
have  little  effect  in  displacing  the  field  trains  to  the  rear. 

Field  hospitals  with  organizations  marching  when  hostile  contact 
is  expected  march  with  the  ambulance  companies  in  advance  of 
the  field  trams,  some  6^  miles  from  the  head  of  the  main  body  in  posi- 
tion to  halt  in  readiness  to  establish  or  march  forward  according  to 
the  necessities ;  should  the  division  deploy,  this  position  in  the  column 


64  MILITARY   SANITATION    AND   SANITARY    SERVICE. 

puts  them  v/ell  up  to  the  front  and  clears  them  from  bemg  involved 
in  the  field  trains  should  action  occur.  This  is  essential,  as  the  trans- 
portation of  these  organizations,  field  wagons,  is  heavily  loaded  and 
can  not  move  with  rapidity.  Position  of  these  organizations  farther 
forward  with  the  column  would  expose  them  to  involvement  in  the 
movements  of  the  combatant  troops  and  possibly  to  artillery  fire  with 
no  advantage,  as  these  organizations  will  not  ordinarily  be  needed 
mi  til  the  action  has  well  developed,  and  in  their  present  position  have 
ample  time  to  establish  whenever  ordered. 

Field  hospitals  attached  to  brigades  acting  independently  conform 
to  the  same  conditions  as  in  the  march  with  larger  units.  Advance, 
rear,  and  flank  guards  of  less  than  a  division  do  not  ordinarily  have 
field  hospitals  attached  to  them  but  depend  upon  the  field  hospitals 
attached  to  the  mam  body. 

In  the  retreat  the  positions  of  the  field  hospitals  are  the  same  as  in 
the  column  on  a  march  to  the  front,  the  advance  when  hostile  contact 
is  expected,  except  that  the  organizations  are  faced  about.  Owing 
to  the  slow  movement  of  these  organizations  the  transportation  and 
material  could  not  be  used  nearer  the  enemy,  but  the  pei-sonnel  will 
be  available  to  assist  the  ambulance  companies  with  litter  bearers,  in 
evacuating  from  the  front,  and  for  care  of  excess  wounded  sent  back  to 
the  sanitary,  field,  ammunition,  and  supply  wagons  for  transportation. 
•  All  movements  of  the  divisional  sanitary  units  other  than  those 
routine  to  the  march  are  directly  controlled  by  orders  from  head- 
quarters of  the  command,  usually  upon  the  recommendation  of  the 
surgeon  of  the  command.  Detachments  for  ambulance  duty  with 
regiments,  advance,  rear,  and  flank  guards,  are  made  by  roster,  where 
possible;  where  organizations  are  on  continued  duty  as  flank  guards, 
etc.,  it  is  advisable  not  to  make  frequent  change  of  sanitary  imits,  on 
account  of  the  unnecessary  movement  involved.  The  orders  with 
regard  to  the  sanitary  troops  may  come  from  the  combatant  com- 
mander, or  from  the  surgeon,  when  such  authority  is  delegated  to  him. 

Under  the  changes  of  the  Tables  of  Organization,  1914,  and  Field 
Service  Regulations  mentioned,  the  Reserve  Medical  Supply  Com- 
pany will  cease  to  exist,  and  it  will  not  be  considered. 

The  relations  of  the  lines  of  communication,  sanitary  service,  to 
the  march  in  campaign  consists  in  the  renewal  of  the  teclinical  sup- 
plies of  the  service,  by  timely  issues,  renewal  of  personnel,  and  the 
evacuation  and  care  of  the  disabled.  With  the  ordinary  march  these 
duties  lie  largely  under  the  control  of  the  surgeon,  advance  group,  of 
the  line  of  communications,  whose  duties  are  practically  those  of  an 
advance  field  and  forwarding  agent  for  the  surgeon  of  the  base  group. 
With  the  line  of  communications  short,  and  near  the  base,  and  efii- 
cient  transport  lines  by  rail,  water,  or  motor  between  the  base  and 
the  transportation  head,  there  will  be  little  intervening  in  the  way  of 


SANITARY    SERVICE    OF    THE    MARCH    IN    CAMPAIGN.  65 

sanitary  establishments  or  e(iuipment;  but  as  the  hne  extends,  estab- 
lishments and  units  must  be  brought  up  and  pLaced  in  accordance 
with  conditions  and  requirements.  Under  the  conditions  of  the  long 
line  of  communications,  intermediate  medical  groups  maybe  required. 

The  duty  of  supply  for  the  sanitary  units,  which  start  the  cam- 
paign with  sufficient  medical  supplies  for  one  month,  will  be  handled 
by  timely  issue  from  the  advance  medical  depot,  usually  at  a  rail, 
water,  or  motor  head.  These  supplies  for  issue  must  be  sent  for- 
ward to  the  distributing  point  by  lines  of  communications  trans- 
portation (as  the  abolition  of  the  Medical  Reserve  Supply  Company 
l)y  recent  action  furnishes  no  supply  wagons  for  this  purpose) 
and  will  there  be  taken  over  by  field  wagons  of  the  ambulance  com- 
pany and  field  hospital  companies,  which  will  issue  to  the  organiza- 
tions, as  required.  Requisitions  for  supplies  required  will  come 
from  the  chief  surgeon  of  the  units  requiring  these  supplies,  and 
probably  they  will  be  issued  under  his  direction.  This  matter  of 
issue  under  the  new  conditions  has  not  been  worked  out  as  yet,  but 
the  method  given  follows  the  former  method.  Issues  to  regimental 
.sanitary  service  can  be  made  by  using  the  regimental  pack  mule  as 
transport,  or  by  the  camp  infirmary  wagon  attached  to  each  brigade. 
The  tecluiical  supplies  required  consist  of  medicines,  dressings,  and 
hospital  stores,  such  as  arrowroot,  chocolate,  extract  of  beef,  spices, 
soap,  candles,  evaporated  milk,  tinned  soups,  etc.,  all  packed  in 
convenient  standardized  containers;  the  medicines  and  foods  in  tin, 
whenever  their  chemical  properties  permit.  Shipments  of  supplies 
of  tliis  character,  on  account  of  the  urgent  need  for  them,  usually 
will  be  accompanied  to  the  distributing  point  by  a  noncommissioned 
officer  of  the  sanitary  service  of  the  advance  group,  in  order  to  insure 
rapidity  and  certainty  of  delivery. 

The  service  of  the  evacuation  of  the  disabled  sick  of  the  marcli 
in  the  campaign  will  be  organized  on  the  same  basis  as  that  for 
those  resulting  from  combats.  The  daily  increment  of  sick  for 
trained  troops  in  campaign,  as  given  by  Straub,  will  average  about 
1  per  cent,  divided  into  the  following  classes: 

J.  Sick  in  quarters:  Percent. 

(a)  Able  to  do  duty  (light) 0.3 

(b)  Unable  to  do  any  duty 3 

2.  Sick  in  hospital: 

(c)  Slight 15 

(d)  Severe 15 


I 


Class. 

Duration 

of 

treatment 

(days). 

Average 

days  of 

disability. 

Day  when 
maximum 
number  is 
reached. 

a 

3 

3-5 
5-14 
14-50 

3 

4 

10 

32 

4 

6 

15 

51 

b 

d         .  . 

98756°— 17- 


66  MILITAEY   SANITATION   AND   SANITARY   SERVICE. 

But  with  relatively  untrained  troops  or  difficult  conditions  of 
march,  weather,  improper  food,  etc.,  these  averages  may  be  much 
increased — even  from  5  to  15  per  cent. 

The  cases  covered  by  classes  (a)  and  (b) ,  amounting  to  6  per  thou- 
sand, will  under  ordinary  conditions  of  march  recover  within  three  or 
four  days;  a  considerable  number  of  these  may  be  able  to  march 
without  equipment  or  ride  on  the  field  wagons  and  be  available  as 
guards,  etc.  It  would  be  uneconomical  to  send  these  to  the  rear,  and 
ordinarily  they  can  be  cared  for  in  the  regiment  or  at  the  camp  infir- 
mary and  sheltered  with  their  own  equipment.  Classes  (c)  and  (d) 
will  average  from  10  to  30  days  lost  by  sickness,  and  will  require  hos- 
pital treatment.  Such  cases  can  not  accompany  the  command,  and 
must  be  evacuated.  Sick  call  will  be  held  by  the  attached  sanitary 
personnel,  and  the  light  cases  separated  from  those  requiring  evacua- 
tion to  the  rear.  The  light  cases  vnJl  be  treated  by  the  regimental 
sanitary  personnel,  or  if  their  equipment  is  sufficient,  at  the  camp 
infirmary;  a  classified  sick  report  will  be  ma-de  to  the  division  sur- 
geon and  the  evacuation  cases  taken  to  the  camp  infirmary  in  order 
that  they  niay  be  collected  by  the  ambulance  detachments  assigned 
to  this  duty.  From  the  brigade  collecting  point  the  evacuation  cases 
are  taken  to  the  field  hospitals,  designated  to  receive  these  cases, 
pending  evacuation,  or  if  the  fines  of  communication,  sanitary  trans- 
port head,  such  as  a  transport  column,  or  hospital  ship,  or  train,  is 
sufficiently  near  to  require  no  extended  movement  by  the  ambulance 
company,  which  in  all  probabifity  has  made  considerable  march,  the 
disabled  may  be  defivered  directly  to  the  fines  of  communication; 
such  conditions  are  unusual,  and  the  chief  surgeon  \\dLl  ordinarily 
require  defivery  to  the  field  hospitals. 

The  director  of  field  hospitals,  fike  the  director  of  ambulance  com- 
panies, will  receive  information  from  the  division  sm-geon  as  to  the 
number  of  evacuation  cases,  and  each  of  these  officers  will  have  desig- 
nated the  units  to  take  care  of  the  transportation  and  shelter  these 
cases,  and  they  vrUl  be  held  at  the  field  hospitals  pending  arrival  of 
the  lines  of  communication,  transport  colunm.  These  cases  for  a 
division  will  amount  to  about  75  men,  of  which  a  considerable  num- 
ber will  be  recumbent.  The  total  sitting  for  an  ambulance  company 
of  12  ambulances  is  at  most  108.  The  total  recumbents  48,  ordi- 
narily, one  ambulance  company  will  be  sufficient  to  collect  them,  and 
for  pm'poses  of  economy  in  travel  that  company  assigned  for  duty 
with  regiments  on  the  march  will  usually  be  designated  as  a  routine 
for  this  duty  by  the  director  of  ambulance  companies,  as  it  has 
marched  in  ■svith  the  regiments  and  is  iJi-cad}^  loaded  \nth  some  of 
the  cases,  and  Mali  collect  the  remainder  while  at  the  regimental  camp 
or  at  the  infirmary. 


SANITARY    SERVICE    OF    THE    MARCH    IN   CAMPAIGN.  67 

The  capacity  of  the  field  hospital  is  216  beds;  it  will  sot  up  such 
bedding  units  as  required  for  the  disabled,  using  available  shelter, 
when  possible,  in  place  of  tentage. 

The  division  surgeon  will  notify  the  hues  of  communications  of  the 
number  and  classification  of  cases  as  soon  as  they  are  reported,  and 
give  the  point  at  which  they  are  collected.  Owing  to  the  fact  that 
lines  of  march  may  be  changed  and  means  of  transportation  fail,  the 
advance  surgeon  will  have  his  transport  column  of  mule  ambulances 
or  motors  well  up  to  the  tail  of  the  column,  in  the  zone  of  advance  at 
all  times,  in  order  that  field  hospitals  may  be  evacuated  as  speedily 
as  possible.  Evacuation  of  the  disabled  will  be  effected  as  rapidly 
as  possible  to  rail  or  water  transportation  heads,  if  practicable,  dis- 
tance, weather,  and  road  conditions  considered.  If  evacuation  can 
be  made  by  rail  or  water,  as  when  the  line  of  march  follows  or  inter- 
sects such  routes  of  transportation,  hospital  trains  or  boats  will  be 
arranged  for  to  arrive  at  a  place  and  time  agreed  upon  by  the  division 
surgeon  and  the  advance  surgeon.  If  evacuation  must  be  by  road, 
such  a  route  should  be  selected  as  wiU  be  different  where  possible  from 
that  traversed  by  the  ammunition  and  general  supply  trains,  in  order 
to  prevent  interruption  and  congestion  of  traffic.  Rest  stations  must 
be  established,  if  the  number  of  wounded  and  distance  of  march  war- 
rant them.  Evacuation  by  rail  or  water  will  require  receiving  detach- 
ments at  the  transportation  head,  with  minor  fixed  hospitals  at  the 
refilling  point,  or  back  farther  on  the  line  for  arrest  of  the  cases  of 
lesser  gravity,  with  rest  and  feeding  stations  for  improvised  ambulance 
trains. 

Dm'ing  the  march  in  campaign  the  evacuation  hospitals  attached 
to  the  line  of  communications  will  be  kept  well  up  to  the  head  of  the 
line,  so  that  they  may  be  available  for  rapid  movement  to  the  front. 
These  units  are  without  specially  assigned  transportation  and  must 
use  water  or  rail  transportation  where  possible. 

Wagon  or  motor  transport  from  the  rail  or  water  head  niust  come 
from  the  lines  of  communication  for  the  final  movement  to  the  relief 
of  the  field  hospitals.  Under  conditions  of  necessity  these  organiza- 
tions may  be  used  as  receiving  hospitals  on  the  lines  of  commimica- 
tions,  but  their  mobility  must  be  impaired  as  little  as  possible,  and 
when  filled,  substitute  organizations  must  be  sent  up  from  the  rear. 

Convalescent  camps  and  sanitary  detachments  may  be  estab- 
lislied  in  the  advance  medical  section  of  the  lines  of  communications 
under  special  conditions,  but  ordinarily  these  will  be  back  in  the  inter- 
mediate or  base  groups. 

The  service  of  supply  of  sanitary  personnel  begins  within  the  home 
territory.  Drafts  of  sanitary  troops  are  forwarded  to  the  base  of 
the  lines  of  communications  and  held  in  causal  camps,  under  the 
control  of  the  surgeon,  line  of  commmiication,  and  under  the  authority 


68  MILITAKY   SANITATION    AND   SANITARY   SEEVICE. 

of  the  commanding  officer,  line  of  commmiication,  assigned  to  duty 
on  the  line  of  communication,  for  organization  of  new  units,  such  as 
fixed  hospitals,  rest  stations,  convalescent  camps,  etc.,  or  to  the 
organization  in  the  zone  of  the  advance.  The  relations  between  the 
sanitary  service  of  the  zone  of  advance  with  the  line  of  communica- 
tion must  be  carefully  accorded,  or  much  difficulty  will  result. 
Constant  communication  must  exist  between  these  sections  and 
between  the  sections  of  the  line  of  communication  themselves,  and 
the  various  officers  of  these  sections  should  be  given  wide  latitude 
as  to  arrangement  of  the  duties  of  their  service. 

The  essential  features  of  the  sanitary  service  in  campaign  are 
prevention  of  disease  and  care,  and  prompt  graded  evacuation  of 
tiie  disabled,  in  such  a  manner  as  to  keep  the  units  organized,  supplied, 
and  unencumbered,  so  that  they  will  be  available  for  use  under  stress 
of  a  large  increment  from  epidemic  or  combat,  and  yet  move  no 
case  farther  to  the  rear  than  his  condition  requires. 


LECTURE  V. 


SANITARY  SERVICE  OF  THE  CAMP. 

The  sanitary  service  of  the  camp  should  begin  with  an  examination 
of  the  camp  site,  as  to  position,  drainage,  soil,  vegetation,  shade, 
evidence  of  recent  occupation,  medical  history  of  the  tract  and 
vicinity,  and  presence  of  objectionable  insects;  the  investigation  of 
source,  purity,  and  quantity  of  water  supply,  and  means  of  distribu- 
tion—food supply,  as  to  quantity  and  quality,  purity  and  method  of 
handling,  and  quantity  and  quality  of  wood  and  straw,  and  location 
and  availabihty,  and  the  location  of  buildings,  roads,  and  means  of 
transportation  that  might  be  available  in  the  care  or  evacuation  of 
the  tUsabled.  Such  an  investigation  should  be  made  for  every  camp 
or  bivouac  by  a  medical  officer,  sent  ahead  with  the  quartermaster, 
who  will  perform  similar  duties  in  conjunction  with  the  medical 
officer. 

Mihtary  necessity  under  stress  of  campaign  or  combat  may  require 
that  the  various  considerations  inquired  into  be  ignored  in  part  or 
altogether — for  very  temporary  camps  or  bivouacs,  for  large  or 
small  commands,  but  early  search  for  proper  sites,  fulfilling  the  con- 
ditions to  be  discussed  later,  will  result  in  such  material  advantage 
to  the  command,  in  the  case  of  supply,  early  establishment  without 
confusion,  comfort,  and  preservation  of  good  feeling  and  health,  that 
such  action  should  never  be  omitted  either  for  march  bivouacs  and 
camps  or  semipermanent  camps. 

The  position  or  situation  of  the  camp  with  relation  to  towns,  vil- 
lages, rail  or  water  transportation  lines,  and  roads  must  be  consid- 
ered from  the  standpoint  of  supply,  shelter,  and  means  of  transporta- 
tion for  the  command  and  the  sanitary  service,  as  well  as  with  regard 
to  transmission  of  communicable  diseases  within  the  native  popula- 
tion, or  in  the  command.  The  situation  of  the  camp  site,  with  re- 
gard to  protection  from  prevailing  winds  or  exposure  to  desirable 
breezes,  proximity  to  insect-producing  streams,  swamps,  or  collec- 
tion of  decomposing  organic  matter;  possibility  of  flooding  in  wet 
weather;  or  dust,  or  sand  storms  in  the  dry  season;  prevalence  of 
fogs,  and  nearness  to  potable  water  and  other  supplies  in  sufficient 
quantity;  and  accessibility  to  transportation  must  be  given  due 
weight.     Poor  drainage  or  a  high  level  of  ground  water  will  not  only 

C9 


70  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

affect  the  comfort  of  the  command  by  keeping  them  constantly 
damp  and  possibly  cold,  but  wiU  actually  conduce  to  transmission 
of  infections,  by  interfering  with  disposal  of  waste,  and  may  pro- 
duce collections  of  water  sufficient  to  produce  breeding  of  diseased- 
carrying  insects — aside  from  the  material  damage  done  to  equipment 
and  dispositions. 

Soil  conditions  such  as  presence  of  a  high  content  or  organic  mat- 
ter, or  clay,  conducing  to  retention  of  moisture,  fine  sand,  to  the  ex- 
tent of  dustiness,  are  objectionable  and  unhealthy  and  should  be 
avoided. 

Rank  vegetation  on  a  camp  site  furnishes  shelter  for  insects,  pre- 
vents drying  of  soil  sufficient  to  permit  a  dry  camp  or  bivouac,  col- 
lects dew  and  rain,  and  in  general  indicates  a  high  organic  content 
and  high  ground  water,  and  should  be  avoided,  or  if  time  permits, 
eliminated.  Excessive  shade  produces  the  same  conditions  that  does 
rank  vegetation  and  should  be  avoided.  Camp  sites  should  in  gen- 
eral be  in  the  open  not  only  to  give  the  sod  the  benefit  of  the  drying 
effects  of  the  sun  but  also  that  most  important  effect,  disinfection. 
Shade  is  as  valuable  and  enjoyable  for  the  soldier  as  for  any  one  else, 
and  shade  trees  in  the  vicinity  of  a  camp  in  the  summer  season  are 
highly  desirable,  but  given  the  choice  of  canvas  under  the  sun  or 
shade,  choose  the' sun. 

Careful  examination  of  the  history  of  cholera  and  typhoid  in  the 
mihtary  service  has  forced  the  conclusion  that  commands,  camping 
on  sites  formerly  occupied  by  infected  contmgents,  have  frequently 
derived  their  infection  by  occupation  of  old  sites,  and  has  led  to  the 
avoidance  of  these  wherever  possible.  Experience  with  typhoid  in 
our  own  service  during  the  Spanish  War,  that  of  the  Enghsh  in  the 
Boer  War,  and  that  of  the  Germans  in  the  Franco-Prussian  War  has 
led  to  this  conclusion,  which  was  confirmed  by  bacteriological  inves- 
tigation of  the  soil  and  water  supply.  The  presence  of  disease-carry- 
ing insects  must  be  considered  with  the  medical  history  of  the  vicinit  y 
of  the  camp;  such  history  can  usually  be  ehcited  by  questioning  thv 
people  hving  in  the  neighborhood,  or  consulting  towni  registers,  or 
health  officers,  with  regard  to  the  prevalence  of  tyj^hoid  fever, 
cholera,  dysentery,  malaria,  yellow  fever,  dengue,  typhus,  and 
cerebrospmal  menmgitis. 

Typhus  is  a  disease  which  wo  need  not  consider  ordmarily  in  the 
United  States  but,  smce  the  constant  prevalence  of  an  attenuated 
form  in  New  York  has  been  proved  by  Brill  and  confirmed  by  the 
discovery  of  the  causative  microorganism  and  method  of  transmis- 
sion by  the  body  louse,  this  disease,  always  present  in  Mexico,  must 
be  of  mihtary  in,terest.  This  particularly  in  view  of  its  appearance 
in  some  European  armies,  under  good  sanitary  control,  in  the  present 
war.     Presence  of  insects,  such  as  fleas,  mosqmtoes,  ticlis,  and  bugs, 


SANITARY  SERVICE   OF   THE   CAMP.  71 

and  lico,  must  not  only  be  considered  from  the  standpoint  of  disease 
carriors,  but  also  from  consideration  of  personal  comfort;  for  wliile 
the  buffalo  gnat,  the  black  flies,  the  Canadian  flies,  and  the  various 
midges,  and  deer  flies  may  not  be  as  yet  implicated  in  the  carriage 
of  diseases,  their  presence  in  considerable  number  not  only  will  worry 
a  command  to  the  point  of  complete  loss  of  rest,  but  they  may  mate- 
rially affect  the  animal  transportation.  Investigation  of  the  water 
supply  vnll  be  made  by  gross  examination,  as  to  color,  odor,  taste, 
with  a  survey  of  the  som"ce,  watershed,  with  an  inquiry  as  to  the 
history  and  use  of  the  water  and  natives  using  it;  and,  if  time  and 
apparatus  be  at  hand,  a  chemical  and  bacteriological  examination. 
The  quantity  must  be  measured,  and  estimation  of  the  amount  re- 
quired by  the  command  must  be  made  on  the  basis  of  the  need,  for 
the  type,  and  duration  of  the  camp,  and  the  character  of  methods  of 
distribution  and  sanitary  installations.  The  food  supply  will  also 
be  investigated  on  the  same  basis  as  is  that  of  the  water,  particular 
attention  being  given  to  milk  and  beverages,  and  method  of  han- 
dling. The  quantity  of  the  local  food  supply  will  be  investigated 
with  view  to  procurement  of  special  diet  articles  for  use  of  the  sani- 
tary establishments,  as  will  also  the  quahty,  quantity,  and  location 
of  wood,  straw,  and  forage  items  essential  to  the  comfort  of  the  sick 
at  all  times  and  to  the  whole  command  in  inclement  weather,  when 
a  timely  certificate,  given  by  the  medical  officer  to  the  quartermaster, 
may  result  in  the  avoidance  of  a  materially  increased  sick  report. 

The  investigation  of  means  of  shelter  and  transportation  and  con- 
dition and  direction  of  roads  may  later  have  an  important  value  in 
the  location  of  sanitary  miits  and  the  evacuation  of  the  wounded; 
and  should  not  be  neglected  by  the  medical  officer,  sent  in  advance, 
as  he  will  usually  have  time  and  opportunities  to  survey  the  country 
before  it  is  occupied  by  troops,  and  can  acquire  a  much  better  idea 
of  the  general  conditions  than  officers  arriving  later. 

Having  reported  the  results  of  liis  sanitary  survey  of  the  camp 
sites,  the  sanitary  inspector  wiU  consult  with  the  advance  quarter- 
master as  to  distribution  of  water  guards  and  water  supply  or  dis- 
tribution points,  and  location  of  unit  camps,  in  order  to  prevent  con- 
tamination. In  large  units,  ordinarily  a  special  quartermaster  and 
sanitary  officer  mU  be  detailed  for  selection  of  the  site,  the  march 
camp,  or  permanent  camp,  and  they  should  coordinate  their  duties 
as  much  as  possible  on  the  basis  of  practical  efficiency. 

SANITARY  ROUTINE. 

Given  the  camp  site  selected  and  the  various  investigations  com- 
pleted, the  sanitary  inspector  reports  the  results  to  the  commanding 
officer,  or  the  chief  surgeon  if  there  be  one.     If  the  camp  is  to  be  a 


72  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

permanent  one  the  sanitary  service  concerns  itseK  with  the  supervi- 
sion of  the  various  sanitary  establishments,  the  details  of  the  hand- 
ling and  periodical  examination  of  the  water  supply,  the  chsposal  of 
waste  water,  and  wastes,  such  as  human  and  animal  discharges, 
kitchen  wastes,  the  examination  of  the  food  supply  and  its  prepara- 
tion, the  investigation  of  the  health  and  habits  of  the  command,  the 
prevention  of  disease  and  the  care  and  evacuation  of  the  sick,  and  the 
organization  and  training  of  the  sanitary  personnel. 

Orders  concerning  the  special  detail  of  the  sanitation  of  the  par- 
ticular camp  are  recommended,  and  periodical  inspection  is  made, 
both  by  the  general  sanitary  inspector  of  the  camp  and  also  by  the 
senior  medical  officer.  Special  sites  for  the  camps  of  cU visional  san- 
itary units  are  arranged  for  and  camp  hospitals  are  established.  Camp 
hospitals  are  a  revived  feature  of  our  service,  the  particular  function 
of  which  is  to  care  for  the  temporarily  or  semipermanently  ill,  pend- 
ing evacuation,  in  order  to  prevent  the  field  hospitals  from  becoming 
immobihzed  with  disabled  and  thus  lose  the  freedom  of  action  neces- 
sary for  training  or  movement  with  the  combatant  organization  to 
which  attached.  The  camp  infirmary  will  be  situated,  where  a  camp 
conforms  to  the  scheme  laid  do^\Ti  in  the  diagram  in  field  service  regu- 
lations, in  such  a  position  as  to  permit  ready  access  from  all  of  the 
regiments  of  the  brigade  to  which  attached,  and  with  personnel 
assigned  by  the  senior  medical  officer  of  the  biigade  from  the  regi- 
ments which  the  infirmary  serves;  and  vnR  be  available  as  a  collect- 
ing point  for  temporary  treatment  and  evacuation  of  the  sick.  Dur- 
ing occupation  of  the  camp  the  ambulance  companies  wiU  be  available 
f(^r  the  transportation  of  the  sick  from  the  camp  infirmaries  to  the 
camp  hospital,  and  from  there  to  the  evacuation  transport  head,  if 
the  command  is  not  under  campaign  concUtions  or  the  distance  too 
far.  In  such  case  the  fine  of  communications,  if  they  exist,  wiU  be 
called  upon  to  perform  evacuation  from  the  camp  hospital.  The 
regimental  sanitary  personnel  will,  in  the  permanent  camp,  busy 
themselves  with  the  physical  examination  of  the  command  with 
respect  to  their  general  physical  condition  and  freedom  from  disease, 
and  fitness  for  the  field,  with  the  examinations  of  recruits,  the  admin- 
istration of  propliylactics  for  prevention  of  infectious  diseases,  and 
the  examination  and  the  care  of  the  sick  and  the  sanitary  inspection 
of  the  camp  site,  and  environs  of  the  command  to  wliich  attached, 
and  the  instruction  of  the  sanitary  personnel  in  tlieir  duties,  and  the 
ofiicers  of  the  combatant  units  in  the  first  aid  and  personal  hj^giene. 

For  purposes  of  instruction  and  duty  the  regimental  sanitary  per- 
sonnel may  bo  divided  into  squadron  or  battahon  sections  as  outfined 
in  previous  lectures.  With  this  system  in  use,  sick  call  will  be  held  ui 
each  battahon  by  the  medical  officer  on  duty  with  the  battahon 
assisted  by  the  noncommissioned  officer  on  duty  with  the  battahon 


SANITARY  SERVICE   OF   THE   CAMP.  73 

Boction  aiid  a.  momoraudiiui  sickroport  sent  to  Uic  n^gimental  surgeon, 
too-ethor  witli  sucji  sick  as  require  treatment  not  afforded  by  the 
personal  equipment.  The  battalion  sick  reports  will  b(^  consolidatcul 
and  the  sick  requiring  special  treatment  or  evacuation  will  be  sent  to 
tlie  cam])  infirmaries. 

As  a  routine,  ambulance  detachments  will  visit  the  (;amp  infii-m- 
aries  twice  daily,  and  specially  in  emergency,  and  clear  them  to  the 
camp  or  field  hospitals.  For  emergency  duty  in  treatment  of  tlie 
sick,  etc.,  one  battalion  sanitary  personnel  miit  mil  be  detailed  for 
(l^ity — the  medical  ofiicer  being  required  to  act  as  regimental  sanitary 
inspector  for  the  day;  to  attend  to  emergency  calls  and  examinations, 
such  as  the  examination  of  recruits,  etc.,  the  enlisted  personnel  assist- 
ing in  this  work,  night  nursing,  etc.,  in  addition  to  their  routine. 

Tlie  duty  tour  for  the  emergency  scpiad  is  usually  24  hours,  during 
which  time  they  will  remain  in  the  vicinity  of  the  regimental  sanitary 
equipment  and  camp.  The  emergency  officer  will  mark  his  tent  by  a 
red  cross  guidon  by  day,  and  a  green  lantern  at  night,  so  that  his 
whereabouts  may  be  known,  and  will  notify  the  emergency  sergeant 
of  his  whereabouts,  if  it  is  necessary  that  ho  leave  the  vicinity  of  his 
duty  and  assignment. 

Each  medical  ofiicer  will  form  a  sanitary  squad  of  his  battalion  imit 
and  will  be  held  responsible  by  the  surgeon  for  the  sanitary  inspection 
and  condition  of  the  area  assigned  to  the  battaUon.  The  sanitary 
squads  will  be  responsible  for  the  sterifization  or  treatment  of  the 
water  for  their  battaUon  and  the  supervision  of  the  details  of  disposal 
of  wastes,  sanitary  police  of  the  area,  including  drainage  and  oiling  of 
pools,  policing  of  latrines,  and  abolition  of  sanitary  nuisances. 

The  battafion  surgeon  will  observe  the  condition  of  the  battaUon 
personnel  as  to  health,  habits,  clothing,  and  food  supply,  making 
frequent  inspections  of  meals;  will  be  charged  with  the  physical 
examination  of  the  personnel  under  his  charge  and  will  be  authorized 
to  make  direct  recommendations  to  the  battaUon  or  company  com- 
manders concerned  for  the  betterment  of  sanitary  conditions  in 
accordance  with  the  poUcy  laid  down  by  the  regimental  surgeon. 

The  division  of  duty  in  this  manner  does  not  reUeve  the  regimental 
surgeon  from  responsibility  or  duty  in  this  connection,  as  he  should 
make  daily  sanitary  inspections  of  the  camp  and  command,  but 
permits  more  rapid  amelioration  of  sanitary  conditions  and  gives  each 
medical  officer  a  definite  personnel  and  miit  to  which  he  is  attached. 
Such  continuity  of  duty  gives  the  medical  officer  a  closer  knowledge 
of  the  individuals  mider  his  care  and  supervision,  and  produces  the 
best  results  in  medical  and  general  service . 

The  enlisted  sanitary  personnel  become  acquainted  with  the 
individuals  of  the  battaUon,  with  which  they  are  on  duty  and  are  able 
to  fiuTiish  valuable  information,  both  to  the  combatant  personnel 


74  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

as  to  sanitary  proceedings,  and  to  the  medical  officer  as  to  the  habits 
of  the  men  as  affecting  their  general  status.  Sick  call  held  in  the 
battalion  area  instead  of  at  the  regimental  aid  station,  will  be  finished 
without  loss  of  time,  and  will  generally  carry  less  malingering  to 
escape  fatigue  duties;  the  service  is  brought  to  the  men,  by  an  officer 
who  knows  them,  mider  conditions  which  will  exist  more  or  less  in 
campaign  for  which  all  are  being  trained. 

The  sanitary  inspections  of  the  camp,  kitchens,  latrines,  incin- 
erators, dumps,  etc.,  will  be  made  at  such  an  hour  that  will  permit 
completion  of  the  routine  poHce  of  these  installations  in  order  to  give 
an  idea  as  to  the  character  of  this  work;  and,  in  order  that  this  may 
be  properly  accomplished,  the  general  sanitary  order  must  fix  a  time 
for  the  completion  of  this  police.  Inspections  will  also  be  made  at 
odd  times  in  order  to  gain  information  as  to  whether  the  maintenance 
of  this  police  through  the  entire  day  is  satisfactory.  Ordinarily  the 
battahon  surgeons  will  accompany  the  regimental  surgeon  on  his  tour 
through  their  areas,  and  the  regimental  surgeon  will  accompany  the 
camp  sanitary  inspector  through  the  regiment.  At  these  inspections 
sanitary  defects  will  be  noted  and  memoranda  made  by  the  inter- 
ested medical  officers.  The  medical  officers  responsible  for  the  areas 
found  defective  will  report  them  to  the  combatant  officer  responsible, 
with  suggestions  as  to  correction,  and,  if  thought  necessary,  to  the 
commanding  officer  of  the  unit,  either  verbally  or  in  writing.  Fre- 
quently camp  or  regimental  orders  require  corrections  of  defects 
reported  by  a  sanitary  inspector  without  requiring  reference  to  the 
camp  or  regimental  commander,  and  it  is  customary  to  invite  atten- 
tion of  regimental,  battahon,  or  company  commander  to  sanitary 
defects  that  require  only  local  action,  without  making  special  report 
to  higher  authority,  making  written  note  of  such  action.  Such  direct 
methods,  if  carried  out  in  proper  manner,  prevent  delays  and  ordi- 
narily accompHsh  the  results  most  satisfactorily. 

The  first  sanitary  inspection  occurs  in  the  fixed  camp  in  the  morn- 
ing, usually  about  9  o'clock,  an  hour  at  which  routine  police  of 
kitchens,  streets,  latrines,  picket  lines,  and  areas  is  usually  com- 
pleted, leaving  the  remainder  of  the  morning  for  administration 
duties  and  instruction.  At  this  time  will  occur  the  biweekly  physical 
examination  of  the  command,  usually  in  the  company  streets,  by  the 
medical  officers  combined,  moving  from  one  battalion  to  another,  in 
order  to  perform  this  duty  as  rapidly  as  possible  with  lack  of  exposure. 
In  camps  where  it  is  difficult  to  secure  security  from  observation  it  is 
well  to  fix  a  time  of  assembly  immediately  after  reveille  for  this  pur- 
pose, at  which  time  there  is  sufficient  light  and  freedom  from  visitors; 
but  in  bad  weather,  incfined  to  be  chilly,  an  hour  nearer  noon  is 
advisable. 


I 


SANITARY   SERVICE   OF    THE   CAMP.  75 

Tlio  administration  of  prophylactics  by  hypodcu-inic  injection  will 
usually  bo  done  in  mobilization  camps,  at  cantonment,  or  field  hos- 
pitals, in  preparation  for  field  service;  but  exposure  to  special  dis- 
eases may  require  administration  in  the  field.  This  will  usually  be 
done  by  combining  all  available  equipment  and  marching  sections  of 
the  command  to  the  camp  infirmaries,  or  if  the  command  be  small,  to 
the  aid  point;  propliylactics  for  prevention  of  venereal  diseases  will 
be  available  at  the  organization  sanitary  aid  point. 

In  camps  of  instruction  and  mobilization,  drill,  and  instruction 
should  be  carried  out  thoroughly,  and  the  regimental  surgeon  will  not 
only  instruct  the  sanitary  troops  proper  in  their  duties  in  camp, 
march,  and  combat,  but  will,  if  authorized,  have  the  band  participate 
with  the  sanitary  troops  in  this  instruction.  The  band  is  an  essential 
aid  to  the  sanitary  service  in  combat  and  must  not  only  receive  drill 
and  instruction  for  this  service,  but  with  the  sanitary  service  receive 
special  physical  training  to  prepare  them  for  the  severe  effort  which 
will  be  required  of  them.  Neither  the  duties  of  the  personnel  of  the 
band  or  of  the  Hospital  Corps  in  time  of  peace  give  them  the  physical 
fitness  that  litter  carriage  requires  and  the  requirements  of  combat 
will  find  them  inefficient  unless  this  is  done. 

The  entire  command  must  be  instructed  in  the  hygiene  of  the  in- 
dividual, and  of  the  camp,  march,  and  battle,  and,  while  the  regula- 
tions require  instruction  by  the  company  officers,  it  is  thought  best 
that  in  preparation  for  campaign  this  instruction  be  given  the  regi- 
mental medical  officers,  who  are  especially  quaHfied  in  this  work. 
The  command  should  be  instructed  in  the  construction,  use,  and 
police  of  the  various  devices  required  in  the  sanitation  of  the  perma- 
nent or  the  march  camp,  and  one  definte  system  should  be  constructed 
and  demonstrated  for  each  condition.  At  present  so  many  types  of 
camp  sanitary  installations  are  used  that  much  confusion  results. 
Most  of  these  devices  are  good,  but  many  of  the  best  require  so  much 
labor,  material,  and  time  in  their  preparation  that  their  construction 
and  use  as  a  means  of  camp  sanitation  is  inadvisable.  In  order  to 
attain  some  idea  of  standard  measures  or  devices  for  camp  sanitation 
these  }vill  be  discussed  as  briefly  as  possible. 

WATER  SUPPLY. 

Amount  required  depends  upon  type  of  camp,  method  of  distri- 
bution or  supply,  sanitary  installations,  and  weather.  Camps  with 
piped  supply  to  company  kitchens,  shower  baths,  and  water  carriage 
sewer  systems  in  hot  weather  will  require  25  gallons  per  diem  for 
each  man  and  10  gallons  for  each  animal.  Bivouacs  and  march 
camps  will  require  a  minimum,  1  gallon  for  each  man  for  drinking 
and  food,  and  from  5  to  7  gallons  to  each  animal.  This  where  water 
must  be  carried  by  hand  for  personal  and  kitchen  use  and  the  ani- 
mals taken  to  it.     For  purposes  of  ablution  and  kitchen  service,  this 


76  MILITARY   SANITATION   AND   SANITABY   SERVICE. 

must  be  increased  by  at  least  3  gallons  per  man.  Requirements  of 
procurement  from  natural  containers  as  streams,  ponds,  springs,  and 
wells  wdll  require  designation  of  special  points  for  procurement  for 
water  for  drinking,  cooldng,  and  for  use  of  animals,  and  washing 
and  bathing,  in  order  to  prevent  pollution  and  soiling;  and  guards 
to  enforce  the  regulations.  These  arrangements  will  be  made  in  ad- 
vance as  mentioned  above  and  required  by  Field  Service  Regulations 
240,  and  consideration  given  as  to  the  most  available  means  of  sort- 
age  and  disinfection  if  such  be  found  necessary. 

Means  for  storage  must  be  taken  in  case  of  insufficient  supply 
early  before  time  of  expected  use,  ordinarily  improvised  from  ma- 
terials at  hand.  In  the  choice  of  these  materials  care  must  betaken 
that  these  are  sufhciently  clean  for  the  purpose,  and  if  there  is  any 
doubt  of  the  purity  of  the  water  or  storage  containers  measures  of 
disinfection  must  be  arranged  for.  At  the  present  date  there  are 
three  methods  by  wliich  this  may  be  accomplished  with  equipment 
at  hand  or  improvised  in  march  camps  or  bivouacs.  Boiling  in  in- 
dividual or  organization  containers,  precipitation  with  chemicals  and 
filtration  with  the  various  types  of  filters,  or  sterilization  by  chemi- 
cals in  special  containers.  Of  these  the  tin  cup  and  canteen,  or  the 
company  kettles  serve  for  boihng;  for  precipitation  and  filtration 
the  Darnall  filter  as  issued  is  satisfactory;  and  for  chemical  sterihza- 
tion  the  Lyster  water  bag  serves  most  satisfactorily,  on  account  of 
ease  of  transport  and  rehabihty.  The  Lyster  bag  is  now  a  part  of 
the  company  equipment.  The  last  two  methods  however  require 
special  equipment  and  are  not  always  at  hand.  Where  possible  the 
matter  of  water  steriUzation  should  be  turned  over  to  the  sanitary 
service,  in  order  to  give  it  responsible  supervision,  and  can  ordi- 
narily be  handled  by  the  battahon  sanitary  detachment,  if  it  is  af- 
forded transportation  or  aid  for  procurement  and  dehvery.  It  can 
be  considered  as  constantly  ti-ue  that  water  from  the  average  stream 
or  pond  in  any  moderately  populated  area  is  infected  and  will  require 
sterihzation.  K  this  is  so,  some  special  sterilization  apparatus  will 
be  necessary.  Of  these  the  most  efficient,  bulk,  weight,  and  de- 
livery considered,  is  the  bag  with  the  chemical  agents. 

For  permanent  camps  the  water  should  be  delivered  in  such  a 
manner  that  it  will  not  require  treatment  by  the  troops  and,  if  such 
action  is  necessary,  treatment  must  be  done  at  a  central  plant, 
under  proper  direction  and  control,  with  the  usual  bacteriological 
checks  by  a  laboratory  designated  for  this  purpose. 

Care  must  be  taken  in  camps  supplied  by  pipe  to  prevent  waste 
and  give  sufficient  drainage  about  points  of  delivery.  It  can  not  be 
too  much  impressed  upon  organization  commanders  that  wells,  as 
sources  of  water  supply,  can  not  but  be  regarded  with  suspicion  with 
regard  to  capacity. 


SANITARY  SERVICE  OF   THE   CAMP.  77 

Ordinarily  there  is  at  hand  no  method  of  judging  capacity  except 
by  the  testimony  of  inhabitants.  Tlic  demands  of  a  single  family 
or  group  of  families  upon  a  given  well  is  usually  so  small  that  the 
ordinary  well  gets  a  reputation  for  inexhaustibility.  The  first  15 
mijmtes  or  half  hour  after  the  arrival  of  a  regiment  fmds  the  water 
taken  from  the  two  or  tlu-ee  wells  available,  roily,  and  another 
quarter  of  an  hour  frequently  finds  them  exhausted.  If  they  are 
not  exhausted  the  constant  demand  has  brought  in  surface  water, 
l(M)  rapidly  filtered  through  the  earth  to  insure  precipitation  or 
nitrification,  and  as  a  result  we  find  the  neighborhood  privy  vault, 
cesspool,  or  barnyard  puddle  contributing  its  moiety  to  the  liquid. 

The  average  reginaent  can  wreck  a  pump,  curb,  and  casing  in  half 
an  hour,  and,  if  method  of  removal  is  not  regulated  and  controlled, 
pollute  the  well  contents  by  drippage  from  dkty  boots  within  that 
time.  The  essentials  for  preservation  of  a  well  and  its  equipment  is  a 
guard  who  will  require  that  no  vessel  smaller  than  a  bucket  is  filled 
at  the  well  and  that  the  method  of  removal  proceed  carefully  under 
his  control  without  wastage,  and  that  no  refilling  be  done  within  40 
feet  of  the  well,  and  that  removed  from  trails  which  would  lead  to 
muddying  and  soilhig  of  the  curb. 

An  almost  indispensable  equipment  for  the  procurement  of  water 
for  a  battalion  or  regiment  in  campaign  is  a  horizontal  marine  pump, 
with  50  feet  of  3-inch  suction  and  25  feet  of  delivery  hose.  Such  an 
apparatus  is  relatively  indestructible  and  will  give  sufficient  delivery 
for  the  command  without  soiling  of  the  source  of  supply.  It  can 
be  controlled  by  one  sentry,  and  worked  by  the  company  water 
detail.  After  a  command  is  trained  to  its  use,  no  sentry  is  required 
other  than  for  general  patrol  of  the  general  water  supply  line. 

FOOD  SUPPLY. 

The  sanitary  service  wiU  examine  the  food  supply  from  aU  sources 
with  regard  to  its  quantity,  quality,  source,  methods  of  handling 
and  preparation,  this  by  inspection  of  the  quartermaster  issues, 
method  of  transport  to  the  organizations,  and  care  and  storage 
therein.  Company  kitchens  and  messes  will  be  inspected  with  regard 
to  their  cleanliness,  the  method  of  storage  and  haTidhng  food,  and  the 
personnel  of  the  kitchen  will  be  scrutinized,  with  regard  to  possibility 
of  their  being  carriers  of  infectious  diseases. 

Under  the  stress  of  march  conditions  and  the  necessity  of  local 
purchases  the  especial  care  in  examining  food  supplies,  that  is  used 
in  time  of  peace  may  not  be  used,  and  supply  from  the  quartermaster 
must  be  as  carefully  inspected,  as  that  offered  for  sale  from  civil 
sources.  Inspection  of  abattoirs,  storage  plants,  butcher  shops, 
groceries,  and  dairies  furnishing  supplies  must  be  made  and  action 
be  taken  to  prevent  entrance  into  camp  of  supplies  from  noninspected 


78  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

and  insanitary  sources.  The  general  provision  that  articles  shall 
not  be  offered  for  sale  within  the  camp  Hmits  except  at  authorized 
estabhshments,  under  military  control,  will  materially  limit  con- 
sumption of  insanitary  foods,  and,  imder  proper  conditions  the 
visiting  of  insanitary  establishments  may  be  forbidden.  With  large 
forces  the  use  of  a  mobile  laboratory  will  materially  aid  the  work 
of  examination  of  food  and  water  supply.  Such  organizations  are  a 
feature  of  the  sanitary  service  of  all  European  armies  and  are  author- 
ized and  have  been  used  in  our  own. 

DISPOSAL  OF  WASTES. 

Like  the  water  supply  the  methods  of  disposal  of  wastes  of  camps 
are  dependent  upon  permanency,  purpose,  and  supply  of  the  camp, 
the  environs,  character  of  the  soil,  the  drainage,  and  the  appropria- 
tion available;  and  the  individual  who  adapts  his  methods  to  these 
conflicting  conditions  will  accomplish  the  best  results. 

Permanent  camps  and  cantonments  will  undoubtedly  save  in  the 
long  run  by  installing  a  proper  water  carriage  system  for  disposal  of 
body  discharges  and  Hquid  wastes,  but  ordinarily  the  initial  expense 
is  too  great  m  consideration  of  the  allotments  for  this  purpose. 
The  danger  of  production  of  epidemic  diseases  by  insect  carriage 
from  human  discharges,  as  proven  within  the  last  20  years,  has 
caused  the  adoption  of  many  expedients  for  the  proper  disposal  of 
feces,  urine,  and  garbage;  aimed  at  prevention  of  contact  with  or 
breeding  of  fhes  in  wastes.  These  vary  from,  destruction  of  wastes 
by  fire  to  storage  and  disinfection. 

Destruction  of  human  wastes  by  fire  is  imdoubtedly  an  ideal  method, 
but  it  has  been  found  expensive,  and  the  various  incinerators  used 
have  been  so  bulky  and  heavy  that  it  is  only  adapted  to  fixed  or 
permanent  camps  and  cantonments ;  and  there  are  other  less  expen- 
sive means  that  have  been  found  effective.  The  average  initial  cost 
per  seat  of  the  latrine  incinerator  has  been  some  $40,  and  while  they 
have  materially  safeguarded  health  these  devices  have  not  been  an 
unalloyed  comfort,  as  anyone  can  testify  who  has  had  his  appetite 
materially  affected  by  fumes  from  the  stewing  contents  of  the  pans 
carried  by  on  an  unpropitious  breeze.  Another  objection  to  these 
latrine  incinerators  is  that  in  ordinary  camps  conditions  will  require 
use  of  some  extemporized  latrine,  usually  some  type  of  trench,  and 
troops  should  be  trained  m  their  use  and  construction  under  favorable 
conditions. 

The  large  camps  are  ordmarily  estabhshed  for  purposes  of  in- 
struction, mobilization,  or  concentration,  usually  with  personnel 
that  requires  instruction  in  general,  and  they  should  here  be  shown  the 
latrine  that  will  be  used  by  them  in  campaign.     For  camps  of  more 


I 


SANITARY  SERVICE   OF   THE   CAMP.  79 

than  one  day,  a  trench  of  sufficient  width  (2  feet),  and  depth  accord- 
ing^ to  probable  duration  of  the  camp,  and  len<^th  proportioned  to 
the  command  it  is  to  serve,  is  required.  Seats  should  be  in  the  pro- 
portion of  1  to  each  10  men  and  length  on  the  basis  of  2^  feet  to 
each  seat.  Field  Service  Regulations,  246,  provides  for  6  feet  as  the 
depth  for  permanent  camps;  such  depths  should  depend  upon  the 
character  of  the  soil  formations. 

Access  by  flies  must  be  prevented  by  police  with  earth  or  other 
suitable  material,  if  fly-light  covers  can  not  be  made,  and  some  means 
of  support  such  as  the  pole  in  ordinary  use  should  be  provided.  It  is 
needless  to  say  that  where  possible  arrangements  should  be  made  for 
seat  covers.  In  arrangmg  the  seat  hole,  it  will  be  found  an  excellent 
plan  to  make  it  sufficiently  long  from  front  to  rear,  and  this  can  be 
done  by  cutting  out  a  notch  in  the  front  and  rear  for  the  purpose  of 
preventmg  contact  with  the  seat,  at  these  points,  and  soiling  by 
urme  and  feces.  A  special  urine  trough  protected  from  flies  by  use 
of  crude  oil  should  be  provided  where  possible.  A  very  necessary 
precaution  to  prevent  flooding  is  the  construction  of  a  ditch  or  dike 
well  away  from  the  trench  to  prevent  access  by  storm  water.  The 
burning  of  oil  and  straw  or  similar  material  does  not  accompUsh 
disinfection  to  any  extent,  but  does  destroy  fly  eggs  laid  on  the  surface 
and  furnishes  a  layer  of  oily  ashes  and  soot,  which  covers  the  surface 
and  walls  of  the  pit  and  renders  it  repugnant  to  flies.  A  growing 
practice  in  burning  out  of  latrines  is  to  do  this  without  removing  the 
box.  This  method  prevents  the  constant  removal  of  the  box,  with 
necessity  for  closing  up  crevices,  and  fills  the  interior  and  all  cracks 
with  a  smoky  soot,  that  serves  to  keep  fhes  away.  If  properly 
handled  the  boxes  and  shelter  will  not  be  burned.  The  only  objection 
to  this  method  is  that  the  seats  become  smoked  and  blackened  and 
are  unsightly. 

Straddle  trenches  of  the  width  of  a  spade,  the  length  of  a  spade 
and  handle,  and  the  depth  of  half  of  the  length  of  a  spade  and  handle 
are  provided  for  one-night  march  camps.  These  are  provided  in  the 
proportion  of  1  to  10  men,  and  should  be  placed  parallel  to  each 
other,  with  long  axis  parallel  to  the  company  street,  at  a  considerable 
distance  away,  so  as  to  permit  construction  of  new  trenches  of  neces- 
sity, nearer  the  company,  in  order  that  filled  trenches  must  not  be 
traversed  in  going  to  new  ones.  The  earth  removed  should  be 
thrown  to  the  end  nearest  the  company  instead  of  on  the  long  sides 
and  used  for  poUcing.  The  psychology  of  the  use  of  the  straddle 
trench  is  interesting.  All  latrines  should  be  located  and  drained 
in  such  a  manner  as  to  prevent  pollution  of  the  water  supply. 

In  permanent  camps  urine  cans  should  be  used  in  the  company 
streets,  between  darkness  and  reveille,  to  prevent  pollution  of  the 


80  MILITARY    SANITATION   AND   SANITAEY   SERVICE. 

camp  ground.  The  garbage  cans  used  for  this  purpose  should  be  re- 
moved and  emptied  immediately  after  reveille  in  the  latrine  for  this 
purpose  and  burned  out  and  suimed.  Lights  should  be  kept  burn- 
ing in  the  latrmes  and  at  the  uruie  cans  during  darkness. 

In  addition  to  the  means  for  disposal  of  human  discharges  given, 
the  Reed  trough,  with  the  so-called  odorless  excavator,  has  been 
used  at  times.  These  have  been  found  dirty  and  objectionalde, 
besides  liable  to  disarrangement.  In  permanent  camps  with  high 
ground  water,  as  found  on  the  coast  or  in  river  villages,  difliculty 
wiU  be  foimd  with  trench  latrines  here;  a  dry  earth  system  will  be 
found  the  least  expensive  in  actual  cost,  but  here,  as  weU  as  with  the 
Reed  trough,  objection  on  account  of  liability  of  scattering  removed 
material  can  be  raised. 

Kitchen  waste  of  permanent  camps  or  semipermanent  camps  is 
best  disposed  of  by  incinerators,  preferably  in  the  camp  kitchen 
incinerator,  which  if  properly  constructed  and  administered  wiU  dis- 
pose of  all  dry  and  liquid  garbage  of  the  company,  including  waste 
proper  and  sweepings.  The  essentials  of  this  sanitary  installation 
are  simplicity  of  construction  and  management,  with  efficiency  and 
economy  of  fuel.  Various  devices,  such  as  the  beehive,  the  Alamo, 
and  many  others  have  been  used  and  all  have  merit;  but  most  of 
them  require  considerable  time,  labor,  and  special  material,  and 
have  not  the  almost  universal  apphcabdity  of  the  simpler  fonns. 
Of  these,  probably  the  simplest  is  a  trench  4  feet  long,  2  feet  wide, 
and  1  foot  deep,  filled  with  stones  throwm  in  loosely  to  the  ground 
level.  On  the  long  side  of  the  trench,  stone  walls  1  foot  high  and  18 
inches  wide  are  placed  and  backed  by  earth.  Such  a  trench  wiU 
accommodate  two  or  three  sticks  of  cordwood,  and  if  kitchen  liquids 
are  poured  over  the  stones  on  the  sides  and  ends  in  small  amomits 
from  time  to  time,  will  consume  these  and  aU  of  the  relatively  dry 
garbage  of  the  company.  The  ends  are  left  open  for  the  removal  of 
debris,  draft,  and  the  placing  of  wood.  Experiments  have  shown 
that  sufficient  heat  for  evaporation  from  an  ordinary  fire  penetrates 
the  stone  bed  only  to  the  distance  of  1  foot,  and  additional  depth  is 
not  only  a  waste  of  labor  but  objectionable  in  that  it  creates  a  layer 
of  undestroyed  putrescent  material  at  the  bottom  of  the  trench. 
The  stones  selected  for  use  m  these  incuierators  should  be  about  s 
or  10  inches  m  diameter  and  as  fire  resistant  as  possible.  These 
incinerators,  owing  to  destruction  of  the  stone  by  heat  and  water, 
require  reconstruction  from  time  to  time.  For  a  company  of  ordi- 
nary size,  larger  pit  incinerators  are  unnecessary  and  wasteful  of 
fuel.  The  incinerator  trench  should  be  diked  or  ditched  to  present 
floodmg. 

In  addition  to  the  ordinary  garbage,  tm  cans  should  be  weU  burnetl 
out  to  destroy  organic  matter.     Incinerator  debris  should  be  re- 


SANITARY  SERVICE   OF   THE   CAMP.  81 

moved  twice  daily  and  stacked  for  removal.  As  it  is  iiuiocuous,  it 
need  not  be  covered. 

Experience  has  shown  that  many  difficulties  of  administration  and 
control  cause  the  larger  improvised  mcineratoi's,  made  for  use  of 
battahons,  to  be  inefficient  and  uneconomical.  The  company  in- 
cmerator  has  proven  its  worth,  is  subject  to  direct  control,  and 
should  be  used  as  a  matter  of  training. 

Kitchen  wastes  are  usually  disposed  of  in  march  camps  and 
bivouacs  by  use  of  kitchen  sink  pits,  with  diameter  and  depth  varied 
to  suit  the  size  of  the  command  and  the  length  of  use.  They  should 
be  poUced  with  earth  and  ditched  in  a  manner  similar  to  trench 
latrines.     All  trenches  must  be  filled  and  banked  on  breaking  camp. 

The  disposal  of  manure  and  care  of  the  picket  lines  is  important, 
in  view  of  the  fact  that  the  most  common  source  of  flies  m  camps  are 
collections  of  manure.  While  flies  will  breed  under  favorable  circum- 
stances in  almost  any  decomposing  organic  matter,  which  is  not 
repulsive  or  poisonous  to  them  on  account  of  the  contained  chem- 
icals, their  chief  breeding  ground  is  excrement  of  animals  and  man. 

Ordinary  police  of  the  camp  is  usually  sufficient  to  prevent,  de- 
stroy,- or  remove  ordinary  collections  of  organic  matter,  but  the 
ubiquity  of  horse  droppings  and  the  urine-soaked  ground  of  the 
picket  hne  afford  excellent  breeding  places  which  are  promptly  used 
by  ffies.  Under  ordinary  weather  conditions  of  summer  the  fly 
matures  in  from  10  to  14  days,  and  destruction  of  organic  material 
must  occur  within  this  lesser  hmit.  In  order  to  prevent  increase  of 
ffies,  action  must  be  taken  to  hmit  movements  of  horses  and  mules 
in  the  vicinity  of  the  camps  to  the  limits  of  the  corral  and  designated 
roads,  which  wOl  be  regularly  pohced  and  require  special  attention 
to  the  removal  of  all  droppings  in  and  near  the  camp  area.  Action 
must  be  taken  to  designate  hitching  points  for  animals  and  forbid 
general  entrance  to  camp  streets.  Tlie  manure  should  be  gathered 
from  the  roads,  picket  hues,  and  camps,  and  removed  to  a  distance 
from  the  camp  and  burned.  If  arrangement  is  made  with  civilians 
to  dispose  of  this  for  fertilizer,  care  must  be  taken  to  see  that  it  is 
removed  at  least  a  fly  ffight  from  camp,  and  preferably  spread  out  on 
the  ground  it  is  to  cover. 

Thin  layers  of  manure  will  dry  out  sufficiently  to  furnish  no  avail- 
able pabulum  for  larvae,  and  are  not  objectionable.  Horse  manure, 
unbroken,  is  covered  by  a  fine  pelhcle  of  mucus,  which  favors  reten- 
tion of  moisture  and  development  of  larvae.  When  this  is  broken  it 
dries  quickly  and  is  unfavorable  soil  for  growth  of  maggots. 

The  soil  of  stalls  and  of  the  picket  fines  is  a  fruitful  source  of  ffies, 
however  well  they  are  swept,  as  the  maggots  find  a  hospitable  environ- 
ment and  rich  food  supply  in  m-ine-soaked  earth,  and  penetrate  it 
frequently  to  the  depth  of  6  inches  and  undergo  transformation  into 

98756°— 17 6 


82  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

the  perfect  fly  and  emerge  from  the  burrows  ready  to  play  their 
distinct  game  of  pussy  wants  a  comer  between  the  camp  latrine  and 
the  soup  tureen. 

Careful  scraping  of  the  picket  line  to  the  depth  of  an  inch  or  so, 
and  thoroughly  burning  over  with  straw  and  petroleum  three  times 
a,  week  will  destroy  eggs  and  immature  larvae  which  will  not  have 
penetrated  far  beneath  the  surface  in  the  short  interval  of  time  be- 
tween burnings.  It  would  seem  that  consideration  of  the  life  history 
of  the  fhes  and  the  probability  of  the  short  duration  of  march  camps 
would  not  require  enforcement  of  the  sanitary  measures  outhned  for 
disposal  of  wastes  of  camps  of  an  impermanent  nature.  It  must  be 
remembered,  however,  that  the  single  organization  represented  in  this 
camp  may  be  followed  by  others,  and  the  same  considerations  that 
caused  the  selection  of  this  site  may  cause  selection  by  another  in  this 
vicinity,  and  that  the  command  must  not  only  take  the  sanitary  pre- 
cautions outhned  to  protect  themselves  now,  but  the  other  organiza- 
tions of  the  zone  of  the  advance,  those  of  the  lines  of  communica- 
tions, and  the  civil  inhabitants  of  the  territory  occupied  are  entitled 
to  consideration.  These  sanitary  measures  are  not  only  directed  to 
prevention  of  production  of  insects,  but  also  to  the  prevention  of 
carriage  of  disease  by  them. 

Many  insects  are  merely  mechanical  carriers  of  disease,  and  a  fly, 
in  being,  may  dabble  in  the  seductive  dehghts  of  typhoid,  cholera,  or 
dysentery  stool  and  furnish  a  company  with  all  of  the  invalidism  it 
wants;  or  transfer  glanders,  tetanus,  or  what  not  in  the  way  of  dis- 
ease, from  soil  or  sore,  to  the  heaUng  abrasion  on  the  back  of  3^our 
hand;  or  the  flooded  latrine  trenches  may  spill  their  uncovered  con- 
tents into  the  first  available  stream  and  give  not  only  typhoid  to  the 
unvaccinated,  but  its  first  cousin,  paratyphoid,  to  the  first  unin- 
oculated  individual  who  drinlis  from  the  brook. 

DIVISIONAL  SANITARY  UNITS. 

The  service  of  ambulance  companies  has  been  outhned  in  general 
for  the  camp  and  march  in  previous  lectures.  The  organizations  camp 
together  in  the  permanent,  semipermanent,  and  march  camps  where 
possible,  unless  they  are  separated  for  some  special  duty,  when  thosi 
organizations  so  separate,  as  with  an  advance  flank  or  rear  guard 
camp,  in  advance  of  the  trains  of  the  organization  to  which  attached. 
This  on  account  of  the  fact  that  the  nature  of  tliis  detacliment  ordi- 
narily imphes  likelihood  of  hostile  contact.  Whatever  the  natm*e  of 
the  duty,  they  are  camped  in  a  position  to  give  them  ready  access  to 
the  front  and  rear,  in  order  to  facilitate  movement  on  the  execution 
of  their  duties,  usually  on  a  crossroads  giving  roads  that  lead  to  the 
various  sectors  of  the  front.  These  organizations  camp  in  column  of 
companies,  as  does  i\j-tillery,  with  a  depth  of  350  yards  and  a  brcadtli 


SANITARY  SERVICE    OF    THE   CAMP.  83 

of  100  yards,  allowing  25  yards  to  a  company,  including  intervals. 
Accessibility  to  water  is  essential  to  these  organizations,  owing  to 
their  considerable  number  of  animals,  78  to  each  company.  Where 
field  hospitals  ai'e  camped  with  ambulance  companies,  as  in  a  division, 
the  total  of  animals  is  484.  Under  march  or  war  conditions  the  camp 
of  these  organizations  should  be  such  as  to  permit  their  retaining 
their  place  in  the  column  without  countermarching. 

Aside  from  the  duties  of  evacuation  and  transportation  of  the  sick 
and  issue  of  medical  supplies  to  organizations  attached  to  the  com- 
batant troops,  these  units  are  in  part  charged  with  the  procurement 
of  additional  supplies  from  the  line  of  communications  and  perform- 
ance of  guard  duty  for  field  hospitals,  besides  performing  their  own 
camp  and  stable  guard. 

Field  hospitals  in  semipermanent  camps  have  little  to  do  with  the 
care  of  the  sick  where  camp  infirmaries  and  camp  hospitals  are  pres- 
ent. Their  duties  as  outhned  in  the  Manual  for  the  Medical  Depart- 
ment are  the  temporary  care  of  the  disabled  pending  evacuation, 
and  they  are  the  nightly  collecting  points  on  the  march  or  in  tempo- 
rary camps  for  the  individual  sick  who  are  unable  to  continue  the 
march. 

Filling  them  up  with  disabled  would  immobilize  them  and  prevent 
mobihty.  In  any  camp  no  more  field  hospital  equipment  is  estab- 
lished than  is  necessary  for  the  care  of  the  sick,  and  usually  one  field 
hospital  or  part  of  a  field  hospital  is  detailed  for  this  duty  by  roster. 

In  march  camps  in  campaign  field  hospitals  ordered  to  estabhsh 
usually  do  so,  taking  advantage  of  such  buildings  as  are  available  to 
save  time  and  labor  of  unpacking  tentage,  and  accumulate,  as  early 
as. possible,  straw  bedding  and  special  diet  supplies,  over  the  emer- 
gency supplies  caiTied  in  preparation  for  the  daily  increment  of  sick. 
The  field  hospital  designated  for  this  duty  can  be  marched  at  the  tail 
of  the  column  in  order  to  permit  early  establishment,  and  will  ordi- 
narily be  ready  for  action  by  the  time  the  disabled  are  brought  to 
them;  the  remaining  organizations  camp  with  the  sanitary  train, 
guarded  by  personnel  from  the  ambulance  companies.  The  field 
hospitals,  as  well  as  the  ambulance  companies,  carry  reserve  medical 
stores  and  wiU  from  time  to  time  issue  and  refill  from  those  sent  up 
from  the  advance  depot  of  the  fine  of  communications. 


LECTURE  VI. 


SANITARY  SERVICE  IN  COMBAT. 

ATTACHED  SANITARY  TROOPS— INFANTRY,  CAVALRY,  ARTILLERY,  EN- 
GINEERS, SIGNAL  CORPS. 

The  duties  of  sanitary  troops  in  combat  are: 

1 .  Care  of  the  wounded  by  application  of  appropriate  measures  for 
their  temporary  treatment. 

2.  The  collection  and  evacuation  of  the  wounded,  with  care  and 
distribution  to  the  various  estabUshments  according  to  the  gravity 
of  their  wounds  and  probable  duration  of  disability. 

3.  The  separation  of  the  disabled  from  the  nondisabled  and  action 
to  return  the  nondisabled  to  duty. 

4.  The  preparation  of  records  of  dead  and  wounded. 

5.  The  management  of  the  sanitary  service  and  the  renewal  of  sani- 
tary material  and  personnel  expended. 

6.  The  examination  and  supervision  of  the  interment  of  the  dead 
and  the  sanitary  pohcing  of  the  battle  field. 

The  necessity  for  such  a  service  is  essential  to  preserve  morale 
among  the  combatant  troops  and  to  prevent  depletion  of  the  firing 
line  by  detachment  for  care  of  the  wounded.     Field  Service  Regula- 
tions 344  forbids  combatants,  unless  duly  authorized,  to  take  or  ac- 
company sick  or  wounded  to  the  rear,  and,  in  the  light  of  the  experi- 
ences of  the  Russians  in  Manchuria,  where  the  firing  Hues  were  de- 
pleted by  such  action,  a  provision  of  this  kind  is  necessary.     Fischer 
quotes  Von  Tetlau  as  saying:  "Of  the  Russians,  seriously  wounded 
were  carried  by  four  unwounded  soldiers  and  followed  by  two  meni 
as  companions ;  each  one  who  was  wounded  in  the  leg  supported  by  I 
two  well  comrades,  while  a  third  carried  the  arms.     The  companions; 
never  were  in  a  hurry  to  return  to  their  organizations."     "  Help  should  j 
seek  the  wounded,  not  the  wounded  help,  else  we  open  the  door  wide] 
for  the  (un)woundcd  to  loaf  around." 

Our  tables  of  organization  provide  4  medical  officers,  4  noncom- 
missioned officers,  and  20  privates  of  the  sanitary  troops  for  a  regiment 
of  Infantry.  Three  officers,  3  noncommissioned  officers,  and  12  pri- 
vates and  privates,  first  class,  with  a  regiment  of  Cavalry;  and  3  offi- 
cers, noncommissioned  officers,  and  16  privates  with  a  regiment  of 
Artillery. 
84 


SANITARY   SERVICE   IN    COMBAT.  85 

The  combat  eqiii])ment  of  these  organizations  when  serving  with  a 
brigade  or  division  having  mobile  sanitary  units,  consists  of  1  field 
desk,  1  box  reserve  dressings,  1  medical  and  surgical  chest,  1  bucket 
(galvanized  iron),  1  ax,  1  tent  fly,  2  lanterns,  and  the  personal  equip- 
ment of  the  men  and  officers,  besides  litters,  and  boxes  of  surgical 
dressing  carried  in  the  combat  wagons. 

The  contents  of  the  field  desk  consist  of  stationery,  blank  forms, 
and  books.  As  it  is  doubtful  that  all  of  the  space  will  be  used  for 
these  articles,  the  canny  medical  officer  may  store  dry  medicines  or 
dressings  in  reserve.  Tliis  field  desk  is  can-ied  on  the  regimental 
headquartei*s  wagon.  The  remaining  articles  except  those  of  the 
personal  equipment  are  carried  on  the  pack  mule  for  use  with  the 
regimental  aid  station. 

The  medical  and  surgical  supplies  are  as  shown  in  tables  attached. 

This  gives  with  each  regiment,  in  addition  to  one  first  aid  packet  on 
the  person  of  each  individual,  an  amount  sufficient  for  first  aid  of  a 
regiment  acting  in  conjunction  with  mobile  sanitary  units,  and  suffi- 
cient for  20  per  cent  loss. 

Should  the  regiment  be  acting  independently,  it  will  have  available 
the  contents  of  the  regimental  hospital  equipment,  which  will  be 
pushed  forward  as  a  combined  dressing  station,  field  hospital.  The 
medical,  surgical,  and  sterilizer  chests  and  food  boxes  and  cases  will 
give  much  additional  dressings,  supplies,  and  restoratives,  together 
with  necessary  medicines,  instruments,  appliances,  towels,  and  bedding 
for  12  patients. 

Independent  battalions  such  as  Signal  Corps  carry  the  aid  station 
equipment.  Cavalry  and  Artillery,  having  a  smaller  sanitary  per- 
sonnel, do  not  have  so  much  personal  equipment  and  dressings,  but 
have  a  sufficient  equipment  for  their  necessities. 

Of  means  for  transportation  of  patients,  the  regimental  sanitary 
personnel  has  available  litters,  in  amount  according  to  the  organiza- 
tion, carried  by  the  sanitary  personnel  attached  to  each  battalion 
with  the  headquarters  section,  and  one  litter  belonging  to  each  com- 
pany carried  m  the  combat  wagons  or  all  carried  in  the  combat 
wagons. 

In  the  Infantry,  there  will  be  eventually  available,  8  litter  squads 
of  the  Medical  Department  personnel  and  14  litter  squads  of  the  band, 
provided  the  band  is  kept  to  full  strength.  Usually  this  is  so  with  an 
Infantry  regiment.  The  Cavalry  will  have  at  best,  only  4  litter 
squads  from  the  Medical  Department  troops,  and  the  Artillery  6, 
with  only  6  or  7  company  litters.  If  the  regiment  is  acting  alone  it 
wiU  have  in  addition,  4  ambulances  and  2  field  wagons  attached  to 
the  sanitary  troops.  The  ambulances  can  carry  4  recumbents  and  1 
sitting  or  9  sitting  each,  and  the  wagons  4  or  5  moderately  w^ounded 
in  the  usual  proportions  of  recumbents  to  sitting  3  to  5 ;  the  wheeled 


86 


MILITARY   SANITATION   AND   SANITARY   SERVICE. 


transportation  can  carry  in  an  infantry  regiment  on  tlie  sanitary, 
combat,  and  ration  and  baggage  sections,  field  and  combat  trains,  12 
recumbents  and  72  sitting  cases,  these  latter  including  the  able  to 
walks,  to  the  field  hospitals,  some  28,  if  necessary. 


FIELD  WAGONS 

Combat. 

Baggage. 

Kation. 

Equals. 

10 

4 

1% 

4 
5 

6 

8 
17 

28 

22 

26 

(-) 

Carriages. 


2  Plenty. 


As  noted  in  the  sanitary  service  of  the  march,  the  position  of  the 
surgeon,  the  battalion  sanitary  personnel,  and  the  headquarters  sec- 
tion of  the  sanitary  personnel  was  that  which  placed  them  in  a  satis- 
factory situation  with  respect  to  the  command,  either  for  the  service 
of  the  march  or  combat. 

In  preparation  for  combat  the  surgeon,  up  with  the  commanding 
officer,  has  already  traversed  the  ground  to  the  rear  of  the  probable 
position  and  is  informed  as  to  the  terrain  and,  with  the  commanding 
ofTicer  will  examine  the  terraui  to  the  front  with  a  view  of  determining 
the  probable  positions  of  the  combatant  troops  and  probable  covered 
lines  of  communications  to  the  rear  as  representing  the  course  of  drift 
of  the  wounded.  He  will  be  informed  of  the  plans  of  the  regimental 
commander  and  in  consideration  of  these  plans  will  make  recom- 
mendations as  to  the  probable  site  or  action  of  the  regimental  aid 
station.  Such  action  must  be  dependent  upon  the  type  of  action  to 
occur.  If  it  be  a  planned  attack,  the  surgeon  will  select  a  tentative 
site  for  an  aid  station  and  hold  his  equipment  in  readmess,  pendmg 
the  development  of  the  action.  This  organization  will  not  be  needed 
for  some  time  and  should  not  be  established  until  there  is  a  definite 
use  for  it.  Changes  of  disposition  may  requu-e  disestablishment  and 
change  of  position,  a  thing  not  difficult,  unobjectionable  when  neces- 
sary, but  nevertheless  undesii-able  when  required  through  the  fault 
of  too  early  establishment.  A  planned  defense  permits  early  estab- 
lishment and  notification  of  the  command  as  to  the  position  of  the  aid 
station  in  combat  orders. 

Rencontre  requires,  for  the  aid  station  and  the  mobile  establish- 
ments, delay  in  estabhshment  until  the  positions  of  the  troops  and 
the  conditions  of  the  action  arc  determined.  Usually  demands  of 
wounded  for  estabhshment  will  not  be  immediate. 

Delaying  actions  require  the  earhest  estabhshment  and  evacuation 
possible,  in  order  to  clear  the  wounded  before  the  retreat.  Trans- 
portation, if  available,  should  be  pushed  up  as  close  as  practicable. 
Consider  using  combat  wagons  where  advance  guard  actions  follow 
the  lines  of  a  j)lanned  attack. 


SANITARY  SERVICE  IBT  COMBAT.  87 

The  three  essentials  in  the  treatment  of  the  wounded  in  modern 
warfare  are: 

1.  The  prompt  application  of  a  sterile  antiseptic  dressing  in  such 
a  manner  as  to  prevent  contact  of  matter  to  the  wound  surface  others 
than  the  sterilized  dressings  and  to  maintain  these  dressings  on  the 
wound  to  prevent  this. 

2.  To  describe  the  wound  and  manner  of  dressing  on  the  diagnosis 
tag,  attached  to  the  person  of  the  wounded  man  in  such  a  way  that 
redressing  or  interference  with  the  first  dressing  wiU  not  be  required 
unless  the  diagnosis  tag  justifies  or  requires  such  action,  or  special 
conditions  make  this  necessary. 

3.  To  evacuate  and  treat  the  sick  in  a  manner  to  conserve  their 
strength  to  the  greatest  possible  extent,  with  the  least  morement 
to  the  rear  possible  according  to  their  condition. 

The  necessity  for  prompt  dressing  in  a  skillful  manner  lies  in  the 
strong  probability  that  nature  may  care  for  a  moderate  amount  of 
infective  material  carried  into  the  wound  by  the  wounding  agent, 
but  that  it  may  succumb  to  a  larger  amount.  The  sterile  cotton 
dressings  act  as  a  filter  to  exclude  infectious  agents  and  yet  permit 
the  wound  to  drain  and  dry  while  the  antiseptics  with  which  the 
dressings  are  treated  form  an  unfavorable  medium  for  the  growth  of 
noxious  bacteria. 

In  addition  to  prevention  of  infection,  proper  dressing  diminishes 
loss  of  strength  through  hemorrhage  and  produces  mental  rest. 

The  use  of  morphine  on  the  field  is  a  great  aid  in  securing  freedom 
from  pain  and  worry  and  decreasing  hemorrhage  and  shock  particu- 
larly when  it  may  be  impossible  to  secure  prompt  evacuation.  The 
conditions  of  action  frequently  do  not  permit  evacuation  from  the 
field  until  cessation  of  firing  or  intervention  of  darloiess. 

Tagging  is  necessary :  (a)  To  prevent  interference  with  the  wound 
when  properly  dressed  on  account  of  the  fact  that  clotting  of  blood 
and  serum  in  contact  with  the  antiseptic  in  the  dressing  forms  an 
antiseptic  seal  over  the  wound,  and  to  reopen  it  breaks  this  seal 
and  exposes  the  injury  to  additional  chance  of  infection  and  hemor- 
rhage and  may  interfere  with  reparative  processes  abeady  started. 
Blood  soaked  dressings  in  themselves  are  not  cause  for  change  of 
dressing;  (b)  to  conserve  time  and  energy  and  facihtate  transporta- 
tion and  record.  The  tag  bears  the  name,  rank,  organization, 
diagnosis,  class  of  case,  walking,  sitting  or  recumbent,  nontransport- 
able — treatment,  disposition.  Date  and  name  of  person  caring  for 
him.  They  will  be  affixed  to  sick,  wounded,  and  dead.  The  dupUcate 
retained  in  the  book,  serves  as  a  record  for  casualty  lists,  etc.,  and 
the  original,  as  a  means  of  identification  record,  record  of  treatment, 
movement,  etc.,  prior  to  admission  to  the  field  hospital,  the  first 
organization  of  permanent  regulation  record,  and  serves  as  a  pass 


88  MILITARY    SANITATION    AND    SANITAEY    SERVICE. 

to  the  rear.  By  this  means,  control  of  the  shghtly  wounded  can  be 
had  and  kept  away  from  a  dressing  station  and  field  hospitals,  and 
loafing  of  wounded  and  malingering  can  be  to  a  certain  extent  pre- 
vented. 

During  the  Russo-Japanese  War  this  loafing  and  malingering  among 
the  Russian  womided  was  most  pronounced.  With  the  diagnosis  tag 
properly  made  out,  receiving  departments  of  sanitary  organizations 
may  see  at  a  glance  the  condition  of  the  patient  and  make  proper 
disposition  of  him  without  delay  and  danger  of  reexamination,  and 
change  of  dressing.  Tags  are  affixed  by  the  noncommissioned  officer 
or  officer  of  the  sanitary  service  who  comes  in  contact  with  the  case, 
where  possible. 

In  combat  of  Infantry  the  battafion  sanitary  personnel  will  accom- 
pany the  battafion,  using  their  personal  equipment;  where  time  per- 
mits before  going  into  action,  they  will  draw  additional  dressmgs 
and  carry  them  in  their  haversacks.  As  the  action  will  require  the 
medical  officers  to  be  dismounted,  all  orderfies  or  substitutes  v>ill 
depart  to  the  aid  station  with  medical  officers'  mounts  and  will  be 
available  for  dressers  or  messengers. 

The  noncommissioned  officers  wiU  serve  as  assistants  to  the  med- 
ical officer  and  record  and  dress  cases. 

The  band  in  campaign  will  ordinarily  carry  light  instruments  and 
under  authority  of  the  regimental  commander  may,  when  marching 
in  the  presence  of  the  enemy  habitually  march  with  the  sanitary 
troops,  as  fitter  bearers,  or,  at  the  beginning  of  an  engagement,  be 
reported  to  the  surgeon.  They  should  have  been  well  trained  in  fii-st 
aid  and  duties  of  fitter  bearers,  and  will  be  supplied  with  company 
fitters  from  the  combat  wagons  and  used  by  the  surgeon,  as  a  bearer 
section,  to  be  sent  wherever  lies  the  greatest  need  for  their  services. 

The  sanitary  troops  (in  extended  order)  wiU  be  disposed  of  in  such 
a  manner  that  one  private  shall  cover  the  rear  of  each  company  in 
the  best  manner  possible,  exposure  and  first  aid  considered,  with 
orders  that  they  will  keep  good  observation  and  contact  with  the 
organization  to  which  attached  (and  if  possible  contact  with  the  aid 
station),  whatever  the  movements  of  the  battafion.  If  a  company  is 
detached,  the  private  covering  that  company  must  continue  to  do  so. 
While  it  is  frequently  impossible  to  render  first  aid  to  all  that  faU  it 
is  essential  that  sanitary  personnel  be  in  contact  with  all  troops  for 
the  sake  of  morale,  as  weU  as  actual  service.  It  is  not  intended  that 
immediate  dressing  or  removal  be  made  in  the  face  of  a  dangerous 
fire,  because  few  wounded  need  immediate  attention  so  badly  that 
the  few  individuals  of  the  sanitary  service  should  bo  sacrificed  in  the 
in<lividual  case,  when  many  more  valuable,  the  lessor  womided,  will 
need  their  service.  So  rare  is  the  case  that  needs  innnediate  service 
to  preserve  life  that  of  1,440  casualties  at  Santiago,  none  such  ex- 


SANTTAKV    SERVICE    IN    COMBAT.  89 

istod.  Tho  only  typo  of  case  tluit  ro(|iiir('s  such  att(vntion  is  pos- 
sibly a  homorrhago  from  a  large  vessel,  and  ordinarily,  first  ai<l,  such 
as  can  be  given  on  the  firing  line,  is  of  little  avail  in  these  cases. 
Remember,  a  desperately  woimded  case,  wliile  he  should  have  all  of 
the  attention  that  can  be  given  him,  requires  and  should  have  the 
least  interference  and  movement  possible,  and  in  view  of  results  is 
not  as  valuable  an  asset  to  an  army  as  one  of  lesser  gravity.  Under 
tho  ordhiary  conditions  of  combat  the  sanitary  troops  with  the  firing 
line  do  not  and  can  not  keep  up  with  the  line,  but  keep  it  under  ob- 
servation, mider  cover,  and  taking  advantage  of  cover,  dress  all  cases 
and  remove  them  to  depressions  or  behind  obstacles  that  would  give 
them  protection  from  fire.  Here  the  wounded  of  the  battalion  will 
be  collected  at  a  point  wliich  affords  communication  to  the  rear,  per- 
mittmg  early  evacuation  by  the  litter  squads.  It  will  be  infrequent 
that  conditions  will  permit  early  collection. 

The  position  of  a  battaUon  surgeon  will  ordinarily  be  at  the  rear  of 
the  center  or  inner  flank  of  the  battahon  in  order  to  place  him  on  the 
Hne  of  drift  or  communication  to  the  rear,  and  as  close  up  as  fire  and 
terrain  permit.  He  will  notify  the  enlisted  sanitary  personnel, 
covering  the  companies,  of  his  position  and  keep  in  touch  with  them 
and  the  battalion.  Should  the  battalion  be  considerably  detached 
from  the  site  of  the  aid  station,  he  will  choose  a  collecting  point,  per- 
mitting movement  from  the  front  and  evacuation  to  the  rear,  where 
he  will  collect  the  transport  cases.  Shghtly  wounded  cases  will 
either  be  retm-ned  to  their  units  or  tagged  and  ordered  to  proceed 
through  the  regimental  aid  station  to  the  station  for  shghtly  wounded 
if  such  exists.  After  engagement,  he  will  complete  the  evacuation 
of  the  wounded,  assist  in  the  sanitary  pohce  of  the  field  and  assist 
in  clearing  the  aid  station. 

The  surgeon,  as  soon  as  the  command  is  committed  to  a  position 
or  the  number  of  wounded  warrant  such  action,  will,  under  authority 
of  the  commanding  officers,  choose  a  site  for  the  establishment  of  the 
aid  station.  This  is  usually  established  as  near  to  the  firing  line  as 
the  conditions  of  cover  for  movement  under  fire  toward  the  front  and 
rear,  line  of  drift  of  the  wounded,  shelter  and  supply  of  wood  and 
water  permit.  Given  cover  accessibiHty,  and  proper  lines  of  drift  of 
wounded,  under  protection  from  fu-e,  it  should  be  pushed  as  far 
forward  as  is  possible,  so  long  as  it  will  not,  probably,  be  involved  in 
the  movements  of  the  lines.  The  consideration  of  shelter,  wood, 
and  water  supply  near  at  hand,  while  desirable,  is  not  absolutely 
necessary,  as  the  first  requirement,  if  in  buildings  or  structures  of 
similar  nature,  frequently  draws  hostile  fii'e,  and  wood  and  water 
can  be  brought  up.  Given  other  considerations,  the  aid  station 
should  cover  the  center  in  order  to  equalize  and  lessen  distances. 
The  regimental  aid  station  is  httle  more  than  a  geograpliical  rendez- 


90  MILITARY   SANITATION   AND   SANITARY   SERVICE. 

vous  for  wounded,  where  they  can  be  collected  for  record,  dressed, 
possibly  fed,  sorted,  and  sent  to  the  rear  or  front.  The  knowledge  of 
possibility  of  food  and  care  will  bring  the  wounded  here  and  permit 
organization  of  the  return  of  the  fit,  and  direction  of  movements  of 
ambulants,  and  evacuation  of  transport  cases. 

The  commanding  officer,  combatant  troops,  of  the  battaHon  and 
the  sanitary  troops  with  them  will  be  notified  of  the  site  of  the  aid 
station  by  the  commanding  officer.  The  surgeon  also  will  notify  the 
battalion  surgeon  of  the  site,  the  battaHon  surgeon  will  notify  the 
combatants  and  his  personnel.  Contact  will  be  gotten  with  the 
divisional  sanitary  units  at  as  early  a  time  as  possible,  and  the  dressing 
station  detachments  and  chief  surgeon  notified  of  site  and  conditions. 

When  necessity  occurs,  and  not  before,  the  equipment  will  be 
brought  up,  the  packs  unloaded,  and  the  tent  fly  erected,  if  neces- 
sary. Marks  (peeled  twigs,  blazes,  or  bandages  on  trees  or  posts) 
will  be  set  up,  showing  direction  to  aid  station;  larger  marks  are 
only  advisable  where  they  can  not  be  observed  by  the  enemy,  as 
they  have  usually  drawn  fire  both  in  the  Russo-Japanese  and  Euro- 
pean war. 

The  aid  station  is  organized  into  a  receiving,  dressing,  feeding, 
and  dispatching  section.  The  bearers  of  the  band  are  used  in  evacuat- 
ing from  the  battalions  under  the  band  noncommissioned  officer's 
and  noncommissioned  officers  and  privates  of  the  aid  station  party 
are  used  for  technical  work.  AH  wounded  passing  thi'ough  the  aid 
station  are  recorded  and  those  needing  it  are  tagged.  The  ambulants 
are  directed  to  the  rear  in  parties,  under  charge  of  a  wounded  officer 
or  noncommissioned  officer,  the  shghtly  wounded  to  the  appropriate 
station — and  those  very  lightly  wounded,  who  do  not  require  move- 
ment to  the  rear,  utihzed  or  returned  to  their  organizations,  usually 
escorted  by  the  band  litter  bearers  (armed) .  Here,  as  on  the  filing 
line,  the  least  amount  of  surgical  work  compatible-  with  saving  life 
is  done.  The  greatest  attention  is  paid  to  first  aid,  collection,  sort- 
ing, evacuation  and  organization  of  the  wounded.  Advantage  wiU 
be  taken  of  all  adventitious  materials  or  aids  in  this  work.  Should 
movement  of  the  command  require  it,  the  station  may  be  reestab- 
lished where  necessary,  leaving  the  collected  disabled  in  charge  of 
sufficient  personnel  to  care  for  them  imtil  taken  over  by  the  organ- 
izations at  the  rear.  The  personnel  with  a  battaHon  not  in  action, 
in  reserve,  will  be  utiHzed  to  the  utmost  and  aU  personnel  brought 
back  as  a  reinforcement,  as  they  clear  their  front.  The  pack  mule 
may  be  sent  to  the  rear  to  renew  supplies  during  an  action;  and, 
after  the  action,  must  take  on  supplies  to  give  full  complement, 
according  to  the  supply  table. 

On  conclusion  of  the  engagement,  or  during  a  luU  in  firing,  or 
after  nightfaU  the  bulk  of  collection  and  evacuation  will  take  place. 


SANITARY    SERVICE    IN    COMBAT.  91 

The  extondod  range  and  rapid  lire  aetion  of  modern  arms  will  ordi- 
narily prevent  succor  of  the  wounded  in  the  zone  of  fire,  and  over- 
shots,  the  use  of  wheeled  transport  near  the  rear  of  the  firing  line. 
Here  all  removals  must  be  made  by  hand  or  htter.  The  regimental 
sanitary  troops,  with  band  auxiliary,  will  make  a  search  of  their 
sections,  collecting  the  wounded,  and  tagging  the  dead  alike.  If 
this  is  at  the  conclusion  of  the  action,  the  sanitary  troops  will  be 
accompanied  by  combatant  details  which  will  take  over  the  dead, 
examined  and  tagged  and  listed,  by  the  sanitary  personnel,  for 
burial:  and  in  cases  where  necessary,  assist  the  sanitary  personnel 
in  tlie  collection  of  the  wounded. 

In  case  the  aid  station  has  cleared  in  its  location  at  the  rear,  it  will 
be  moved  up  and  reestabhshed  on  the  field  and  avoid  long  hauls. 
When  the  wounded  are  collected  and  cleared  from  the  aid  stations 
by  the  bearers  or  transport  of  the  ambulance  company,  a  part  of 
the  regimental  personnel  may  be  mthdrawn  to  assist  at  the  dressing 
stations  under  orders  from  the  division  surgeon. 

The  final  pohce  of  the  regimental  section  of  the  battlefield,  after 
removal  of  wounded,  wiU  proceed  under  the  advice  of  the  local 
medical  officer  in  connection  with  the  supervision  of  the  sanitary 
inspector  of  the  division. 

In  trench  warfare  modern  practice  shows  the  best  results  where, 
like  in  the  planned  defense,  the  attached  sanitary  troops  are  in  the 
trenches  with  the  combatants,  with  the  aid  equipment  and  party  in  a 
special  communicating  trench,  in  such  a  manner  as  to  permit  access 
to  all  parts  of  the  hne.  Here,  under  the  protection  of  bombproofs  and 
trenches,  most  satisfactory  work  can  be  done  and  the  equipment  can 
be  much  more  elaborate  and  complete.  Evacuation  to  the  rear  is 
ordinarily  made  in  this  case  under  cover  of  darkness.  The  possibihty 
of  good  roads  under  these  conditions  makes  rapid  evacuation  com- 
paratively easy  and  swift,  and  can  be  direct  from  the  firing  line  to  a 
field,  or  even  an  evacuation  hospital,  or  train,  or  boat. 

Artillery  aid  stations  and  those  of  Cavalry  dismounted  conform  to 
the  action  of  those  of  Infantry,  except  that  care  must  be  taken  in  the, 
case  of  the  aid  station  of  Artillery,  to  establish  rather  on  the  flank 
and  away  from  the  reserve,  as  this  will  ordinarily  be  searched  for  in 
Artillery  combat,  and  the  wounded  will  be  needlessly  exposed.  The 
sanitary  troops  with  a  Cavah-y  regiment  will  ordinarily  estabhsh 
little,  and  devote  most  of  their  attention  to  accompanying  the  com- 
mand, leaving  their  wounded  with  detached  personnel  to  be  taken 
over  by  the  divisional  organizations.  As  the  many  small  engage- 
ments of  Cavalry  preceding  and  during  general  action  will  produce 
many  scattered  casualties  over  a  wide  area,  and  the  aid  party  will  be 
of  httle  use,  it  will  usually  be  advisable  to  keep  the  squadron  units  to 
full  strength.     Owing  to  the  number  of  men  tliat  must  be  left  for  the 


92  MILITAEY    SANITATION    AND    SANITARY    SERVICE. 

temporary  care  of  the  wounded  it  would  seem  that  the  enlisted 
personnel  allowed  were  insufficient.  Owing  to  the  necessity  of  fre- 
quent changes  of  position  and  plan  of  action,  the  regimental  surgeon 
serving  with  the  mounted  organization  as  well  as  those  on  foot  will 
do  well  to  have  a  mounted  agent  with  the  regimental  headquarters 
when  he  is  absent  at  the  aid  stations  or  elsewhere,  in  order  to  ketu 
informed  as  to  the  changes  in  situation. 

THE  AMBULANCE  COMPANY. 

The  personnel  of  the  ambulance  company  consists  of  5  medical 
officers,  2  sergeants,  fu^t  class,  7  sergeants,  and  70  privates,  cooks, 
farriers,  horseshoers,  etc.  The  transportation  consists  of  18  mounts, 
12  ambulances,  and  3  wagons,  and  4  pack  mules. 

The  ambulance  company  for  duty  assignment  is  divided  into  four 
detachments:  The  bearer  detachment,  consisting  of  20  htter  squads; 
the  dressing  station  party;  the  ambulance  detachment;  and  the 
wagon  detachment. 

The  technical  equipment  consists  of  the  personal  medical  equip- 
ment, the  equipment  in  the  packs,  and  dressing  station  wagon,  and 
the  food  and  dressing  boxes  of  the  ambulances. 

The  total  of  dressings,  etc.,  for  combat  care  of  wounded  will  give 
dressings  for  approximately  1,800  cases  and  4,000  cups  or  dishes  of 
restorative  stimulating  food,  such  as  blancmange,  beef  tea,  soup, 
milk  punch,  tea,  malted  milk,  oatmeal,  porridge  or  gruel,  and  choco- 
late. That  is  sufficient  for  10  per  cent  of  casualties,  not  considering 
the  dressings  put  on  by  the  attached  units  or  the  equipment  of  the 
other  ambulance  companies. 

As  given  in  former  lectures  the  ambulance  companies  are  under 
the  direct  control  of  the  director  of  ambulance  companies  and  on 
release  of  this  portion  of  the  sanitary  train  from  the  control  of  the 
commander  of  trains,  will  be  managed  by  him  under  orders  of  the 
chief  of  stafl,  or  surgeon,  during  and  after  combat.  The  activities 
of  the  director  and  the  ambulance  companies  cover  the  entire  zone 
between  the  firing  line  to  the  field  hospital.  Under  the  orders  or 
authority  of  the  chief  surgeon,  he  will  establish  dressing  stations, 
change  their  sites,  and  make  proper  arrangements  for  the  collection 
and  transportation  of  the  wounded. 

The  four  detachments  of  the  ambulance  company  have  usually 
different  sections  on  the  field  for  their  work.  The  bearer  detachments 
collect  the  wounded  from  the  regimental  aid  stations,  or  under  favor- 
able conditions  from  the  field,  and  transport  them  to  the  ambulance 
head,  if  conditions  of  terrain  or  action  permit  use  of  wheeled  trans- 
portation in  advance  of  the  site  of  the  dressing  station.  The  dressing 
station  party  remains  with  the  dressing  station  at  its  site  and  is  rein- 
forced as  may  be  necessary  from  the  personnel  of  the  bearer  section. 


SANITARY    SETtVlCE    IN    COMBAT.  93 

Tlio  ambiiliince  dctachnuMit  transports  tlio  woiindod  from  as  far 
foiward  toward  tlic  actual  field  as  is  possible,  terrain  and  fire  con- 
sidered, to  the  dressing  station  or  field  hospital.  The  wagon  detach- 
ment detaches  one  wagon  with  the  equipment  and  supply  reserve  of 
the  dressing  station  and  sends  it  as  far  forward  toward  the  dressing 
station  as  conditions  permit.  The  other  field  wagons  ordinarily 
remain  back  near  the  divisional  field  trains  when  the  other  detach- 
ments go  forward. 

The  time  and  place  of  establishment  of  the  dressing  station  will 
be  determined  by  the  conditions  of  the  action  and  the  terrain; 
for  a  planned  defense,  they  may  be  established  early  and  the  sites 
stated  in  the  combat  order;  but  for  offensive,  or  rencontre  actions, 
establishment  will  not  be  done  until  the  positions  of  the  troops, 
the  drift  of  the  wounded,  and  the  type  of  action  determines  the 
necessity.  Too  early  establishment  vfill,  in  case  of  an  advance, 
leave  the  station  without  function,  and  require  advance  and  rees- 
tablishment,  or  involve  it  in  the  line  of  fire  or  movement  of  troops, 
in  case  of  rectification  of  lines. 

The  regimental  sanitary  personnel  will  be  able  to  handle  the 
situation  at  the  front  for  a  considerable  time,  and  the  wounded 
who  come  back  early  will  ordinarily  be  ambulants,  who  have  no 
need  of  the  dressing  station.  The  transport  cases  will  hardly  be 
back  to  the  aid  station  during  the  first  hour  of  the  engagement. 
Should  the  lines  advance  materially,  it  will  be  well  to  advance  the 
station  to  the  wounded  and  avoid  littering  the  patients  any  farther 
than  necessary. 

Littering,  at  best,  is  slow  and  exhausting  work,  and  every  effort 
must  be  made  to  abridge  distance.  In  the  earlier  part  of  the  Russo- 
Japanese  War  much  difficulty  of  transport  arose  through  the  tend- 
ency to  too  early  establishment.  In  delaying  actions  with  a  planned 
defense  and  subsequent  retreats,  early  establishment  and  evacuation 
is  necessary,  and  reinforcement  of  the  sanitary  personnel  is  desirable 
and  necessary,  particularly  with  bearer  and  ambulance  detachments. 
Ordinarily  the  time  for  establishment  will  come  when  the  advance 
has  ceased  and  the  regimental  aid  stations  have  more  wounded  than 
they  can  care  for. 

Tlie  division  surgeon  will  determine  where  and  how  many  stations 
^vill  be  opened  and  will  consider  in  this  decision  the  field  of  grc^atcst 
casualties  and  probabihty  of  further  action  as  to  location  and  number 
establishing;  he  may  have  them  establish  individually  or  combine 
and,  if  not  pressed,  %vill  hold  one  or  more  in  reserve  to  reinforce  other 
stations,  or  to  place  in  points  of  future  casualty,  when  the  proper 
time  arrives. 

Tlie  factors  to  be  considered  in  the  selection  of  a  site  for  the  dressing 
station,  given  necessity  and  consistency  as  to  battle  plan  and  actions, 
are : 


94  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

1.  Location  near  a  practicable  route  of  evacuation  from  the  front 
to  the  rear,  usually  on  some  well  marked  line  of  approach. 

2.  Possibility  of  cover  at  site  of  station  from  aimed  and  overshot 
fire. 

3.  Sufficient  proximity  to  aid  stations  to  decrease  transport  dis- 
tance, and,  yet,  not  to  include  station  in  minor  changes  in  lines. 

4.  Proximity  to  shelter;  wood,  water;  buildings  as  shelter  have 
the  disadvantage  of  attracting  Artillery  fire  and  are  therefore  not  an 
unmixed  blessing,  and  wood  and  water  may  be  transported  if  neces- 
sary; but  frequently  the  same  inequality  of  ground  which  affords 
cover  and  covered  communication  to  the  front,  will  give  wood  and 
water. 

The  necessity  for  the  establishment,  on  a  practicable  route  is 
obvious  and,  other  things  being  equal,  should  contemplate  a  point 
wliich  will  intersect  a  line  of.  probable  drift  of  wounded,  who  will,  if 
fire  and  cover  permit,  usually,  follow  the  line  by  which  they  approach 
the  field — the  only  route  known  to  them — and  will  ordinarily  follow 
ravines  or  the  lower  slopes  of  hills,  in  order  to  get  advantage  of  the 
cover  afforded.  Interception  of  these  ambulants  is  necessary  in 
order  to  give  them  proper  direction  and  care,  at  a  time  when  the  sta- 
tion is  relatively  idle  as  they  usually  precede  transport  cases,  and  can 
oe  pushed  back  to  the  station  for  sHghtly  wounded  on  foot,  or  to  the 
field  hospital,  as  their  condition  requires. 

Necessity  requires  that  the  dressing  station  be  as  close  up  as 
possible;  a  distance  beyond  Infantry  or  Artillery  fire  wouM  render 
the  establishment  useless. 

Examination  of  almost  any  field  will  show  sufficient  cover  to 
permit  movement  forward  of  the  personnel  and  equipment  with  pack 
transportation,  which  may  subsequently  be  sent  back  for  supphes. 

On  establishment,  the  bearer  section  will  be  sent  forward  to  estab- 
lish contact  with  the  aid  stations,  ordinarily  dividing  into  two  sec- 
tions of  10  fitters  each,  with  a  definite  sector  assigned,  by  subdivision 
of  the  ambulance  company  sector  assigned  by  the  director. 

The  bearer  sections  will  place  Red  Cross  guidons,  bandages,  or 
peeled  twigs,  as  route  markers,  indicating  the  direction  of  the  dressing 
station,  while  moving  forward  and  will  notify  aU  regimental  per- 
sonnel of  its  location.  The  commanding  officer  wiU  report  time  and 
place  of  establishment  to  the  director. 

The  dressing  station  will  estabfish  the  following  departments: 
Receiving,  dispatcliing,  slightly  and  seriously  wounded,  dressing 
and  dispensing,  feeding,  and  morgue.  AU  patients  received  will  be 
examined,  Usted,  tagged,  if  necessary  sorted,  distributed  or  dressed, 
fed,  and  dispatched  to  the  rear  or  front.  The  sfightly  wounded, 
requiring  evacuation,   will  be  arranged  in  squads,   in  charge  of  a 


SANITARY   SERVICE   IN    COMBAT.  95 

•wounded  ofRcor  or  noncommissioned  officer,  and,  after  feeding, 
marched  to  the  station  for  shghtly  wounded;  those  requiring  move- 
DKMit  to  the  front  turned  over  to  a  provost  officer. 

The  amhulant,  seriously  wounded,  will  be  sent  to  the  field  hospital 
on  foot,  convoyed  by  ambulances  loaded  with  transport  cases;  and 
the  transport  cases  after  being  grouped  as  sitting  and  recumbents, 
loaded  as  such  by  the  dispatching  section. 

No  oj^erations  other  than  those  immediately  necessary  to  save  life 
will  be  done,  such  as  tying  or  clamping  an  artery,  or  opening  the 
trachea;  and  such  operations  will  be  rare.  Feeding  will  be  limited 
to  stimulating  and  restorative  food  and  drinks,  and  has  been  found 
advantageous,  not  only  from  a  standpoint  of  pure  medicine,  but  also 
as  a  means  of  securing  attendance  of  the  slightl}^  wounded,  who 
otherwise  may  straggle  without  control.  Possibility  of  food  and  aid 
brought  many  to  the  dressing  stations  in  the  Balkan  and  Manchurian 
wars. 

For  purpose  of  bringing  up  reserve  supplies  and  collecting  local 
comforts,  such  as  straw,  hay,  etc.,  the  reserve  wagon  will  be  brought 
up  if  possible  and  the  ambulance  detachment  will  establish  ahead 
at,  or  to  the  front  of  the  dressing  station,  where  roads  and  cover 
permits,  in  order  to  decrease  litter  haulage. 

Every  effort  should  be  made  to  prevent  overcrowding  of  dressing 
stations,  and  to  facilitate  evacuation.  Additional  transportation, 
field  wagons  and  local  transport,  may  be  used. 

Neither  the  dressing  station  nor  the  ambulance  detachment  must 
bo  held  back  on  account  of  casual  fire,  but  must  advance  from  cover 
to  cover  until  it  reaches  a  relatively  protected  zone.  Movement  in 
colmnn  will  frequently  draw  fire,  as  at  600  yards,  with  present 
system  of  marking,  an  ambulance  can  not  be  differentiated  from  a 
field  wagon,  so  that  movements  in  evacuation  can  be  frequently 
best  accomplished  by  single  wagons.  The  capacity  of  a  dressing 
station  m  material  has  been  given,  1,500  to  2,000  cases,  the  capacity 
of  the  personnel  is  given  as  from  15  to  20  dressings  per  surgeon  per 
hour  m  fair  weather.  Although  the  Japanese  state  that  at  Mukden, 
two  surgeons  and  two  assistants  placed  25  to  30  dressings  per  hour 
and  could  have  done  30  to  40  in  the  same  time,  in  sununer.  Fischer 
quotes  Schaefer  as  saying  that  it  was  not  unusual  for  a  surgeon  to 
do  24  dressings  in  an  hour. 

With  two  medical  officers,  this  would  give  from  30  to  40,  per  hour, 
a  considerable  number  of  wounded,  more  than  half,  will  be  properly 
tagged  and  dressed,  and  these  will  not  need  dressing,  giving  a  capacity 
of  60  to  80  per  hour  to  the  dressing  station  unreinforced.  If  addi- 
tional help  is  necessary  in  the  early  stages  of  the  action,  it  must  come 
from  the  medical  officers  of  the  bearer  detachment,  who  can  double 
the  capacity  of  the  dressings;  and  if  more  is  needed,  such  can  come 


96  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

from  the  personnel  of  the  field  hospitals  if  they  do  not  go  into  action, 
and  after  the  aid  stations  are  cleared  can  come  from  them;  an()  the 
chief  surgeon  may  direct  such  reinforcement. 

After  fire  has  ceased  and  the  stations  cleared,  the  bearer  detach- 
ment must  search  for  the  wounded.  With  the  combatant  forces  in 
position,  this  can  not  be  done  until  after  nightfall  and  then  under 
difficulties.  The  Manchurian  war  showed  that  moonlight  permitted 
view  of  the  searchers,  and  in  dark  night,  artificial  light  drew  fire. 
While  on  the  western  front  in  the  pan  European  war,  the  close  prox- 
imity of  the  lines  renders  it  almost  impossible,  so  much  so  that  maiiy 
wounded  have  lain  for  days  without  succor.  Systematic  search  will 
be  made  where  possible,  by  assignment  of  sectors,  and  the  wounded 
will  be  evacuated  to  the  ambulances,  which  can  usually  be  brought 
up  under  the  conditions  that  render  this  collection  possible. 

After  clearing  the  wounded  to  the  field  hospitals,  the  director  of 
ambulance  companies  will  usually  receive  orders  to  pack.  If  help  is 
needed  at  the  field  hospitals,  personnel  will  be  assigned  from  tlie 
ambulance  companies  for  this  purpose;  and  the  ambulance  compani(>s 
will  bivouac  on  the  field  with  the  command  or  camp  with  the  field 
liospitals,  as  directed. 

The  work  of  these  organizations,  both  for  men  and  animals,  is 
exceedingly  arduous  and  without  regard  to  hours.  Under  condi- 
tions of  combat  and  after,  Httle  rest  can  be  given.  Great  care  mu^t 
be  taken  to  secure  the  most  economical  use  of  these  organizations,  in 
order  to  prevent  exhaustion. 


LECTURE  VII. 


SANITARY  SERVICE  IN  COMBAT. 

STATION    FOR    SLIGHTLY    WOUNDED— FIELD    HOSPITAL    COMPANIES, 
ADVANCE  GROUP,  LINE  OF  COMMUNICATIONS. 

This  is  an  establishment  of  our  sanitary  service  created  as  a  result 
of  experience  gained  in  the  Civil  War  and  emphasized  by  observa- 
tions during  the  Russo-Japanese  War.  It  has  been  adopted  by  the 
Austrians,  British,  and  Germans,  following  our  example. 

This  station  is  established  for  the  purpose  of  diverting  the  ambu- 
lant slightly  woimded  from  the  field  hospitals,  and  evacuation  hos- 
pitals. If  they  have  been  given  a  definite  dressing  by  the  regimental 
personnel  these  wounded  can  be  sent  directly  to  the  slightly  wounded 
station,  without  mterfering  with  or  encumbering  the  service  of  the 
dressing  station  and  field  hospitals. 

The  cases  sent  to  these  stations  are  the  slightly  wounded  ambulant 
cases,  who  are  capable  of  marching  back  to  the  railhead  or  if  neces- 
sary to  the  convalescent  camps  or  establishments  for  slightly  womided 
in  the  advance  group  of  the  Ime  of  communication,  on  their  own  feet. 
Such  cases  comprise  wounds  of  the  upper  extremities,  superficial 
wounds  of  the  trunk,  head,  etc.,  which  will  prevent  full  participation 
in  active  service,  but  will,  ordinarily,  be  able  to  care  for  themselves 
and  result  in  early  return  to  their  organizations.  This  class  of  cases 
vvould  fill  the  space  required  for  care  of  the  more  seriously  wounded 
and  add  to  the  burden  of  the  transportation,  if  cared  for  by  the  other 
institutions,  and  straggle,  and  be  lost  from  control,  and  materially 
delay  their  recovery  and  restitution  to  their  organization,  if  turned 
loose  to  make  their  way  to  the  rear  uncontrolled.  Genuine  slightly 
wounded  requiring  control  by  this  station  amount  to  some  12  per 
cent  of  all  casualties,  and  these,  together  with  a  considerable  num])er 
of  cases  of  wounds  so  slight  that  they  should  be  returned  to  their 
organizations,  and  malmgerers  formed  the  contmgent,  who  dui-ing 
our  war  of  the  rebellion,  and  the  Russo-Japanese  War,  particularly 
in  the  Russian  service,  the  bulk  of  the  straggling  wounded  who  were 
annoying;  as  they  were  not  only  disorderly,  but  caused  material 
depletion  of  the  total  of  rifles.  Such  cases  were  seized  upon  by 
enthusiastic  citizens  in  our  Civil  War,  and  in  the  early  days  in  the 
French  service  of  the  pan-European  War  and  taken,  unrecorded,  to 
98756°— 17 7  97 


98  MILITARY    SANITATION    AND   SANITAKY    SERVICE. 

the  rear  in  great  numbers.  They  were  lost  to  the  services  for  con- 
siderable periods  of  tune  and  contributed  much  to  permanent 
absenteeism. 

The  station  for  slightly  wounded  assists  much  in  the  sorting  pro- 
cess and  may  catch  a  considerable  number  of  more  serious  cases, 
which  can  be  detained  and  sent  with  proper  transportation  to  the 
field  hospitals. 

Under  proper  administration  of  the  sanitary  service  no  wounded 
man  should  be  permitted  to  move  farther  to  the  rear  than  the  field 
hospitals  or  aid  stations,  when  not  in  custody  of  the  sanitary  service ; 
and  no  woimded  man  should  be  permitted  to  move  in  the  zone  in 
front  of  the  field  hospitals  and  aid  station  untagged  or  unattended. 
Such  requirement  will  ensure  control  of  wounded  and  give  the  best 
results  m  economy  of  service.  Malmgerers  and  trivial  case  will 
not  find  encouragement  or  license,  and  will  remain  with  their 
organizations. 

The  routine  in  the  past  for  the  battle  malingerer  has  been  to  avoid 
contact  with  the  regimental  sanitary  personnel,  by  whom  he  is  gener- 
ally known,  by  skulking,  and  by  attaching  himself  to  some  nonsanitary 
unit  by  affecting  shght  wounds,  gain  the  rear.  The  requirement  of 
constant  sorting  out  and  control  will  make  this  relatively  impossible. 

The  personnel  of  the  station  for  sHghtly  wounded  will  ordinarily 
consist  of  a  medical  officer,  a  noncommissioned  officer,  and  six  or  eight 
men  of  the  sanitary  contingent  and  should  include  a  squad  of  the 
mihtary  police  for  the  control  of  the  trivially  wounded  and  maling- 
erers, and  their  restitution  to  their  organizations. 

The  equipment  of  the  station  for  slightly  wounded  will  ordinarily 
consist  of  dressmgs,  medicines,  food,  and  cooking  utensils,  in  addition 
to  that  of  the  personnel.  Shelter  will  not,  usually,  be  provided,  but 
advantage  will  be  taken  of  buildings  near  the  point  for  estabhshment. 
AH  that  is  needed  at  this  point  is  sufficient  personnel  to  record, 
examine,  readjust  dressings,  and  provide  stimulants  and  restorative 
food,  as  the  cases  will  have  been  dressed  before  arrival.  Some  shelter 
should  be  provided  with  straw  or  improvised  bedding,  as  some  cases 
will  become  exhausted  through  shock  and  loss  of  blood  or  serious  cases 
may  be  picked  up — which  will  require  subsequent  removal. 

The  personnel  and  material  will  come  from  the  ambulance  company 
or  more  commonly  from  the  field  hospitals  as  these  organizations  will 
usually  be  more  or  less  idle  at  the  time  of  estabhshment  and  hardly 
greatly  occupied  until  the  necessity  for  the  unit  has  ceased— when  the 
equipment  and  persomiel  withdrawn  can  most  readily  join  these 
organizations,  as  the  distance  of  these  organizations  from  the  front 
is  somewhat  similar.  The  camp  infirmary  equipment  will  be  avail- 
able. 


SANITARY   SERVICE   IN    COMBAT.  99 

Tlie  sito  for  the  station  for  slightly  wounded  should  be  well  to  the 
rear  on  the  line  of  drift  of  wounded,  well  out  of  range  of  direct  fire, 
preferably  at  a  fork  or  convergence  of  roads  from  the  flank  and  center, 
near  some  easily  recognizable  object  which  can  be  mentioned  as  a 
guide  to  its  location.  For  purpose  of  recognition  of  its  position  this 
object  as  a  church,  school,  monument,  or  natural  formation  should  be 
selected,  where  possible,  from  those  passed  by  the  command  on 
advance  to  the  front.  A  most  satisfactory  distance  from  the  firing 
line  is  one  of  some  2^  or  3  miles,  with  the  understanding  that  the 
slightly  wounded  station  should  be  in  advance  and  well  removed  from 
the  site  of  the  field  hospitals  in  order  to  divert  the  shghtly  wounded 
from  them. 

Owing  to  the  fact  that  these  stations  are  to  be  estabhshed  well  to 
the  reur  and  their  ephemeral  nature,  a  site  can  be  chosen  early  and 
their  location  announced  in  the  combat  order.  Ordinarhy  only  one 
shghtly  wounded  station  is  established  for  a  division  and  none  for 
units  of  lesser  size;  but  where  natural  or  artificial  conditions  render 
it  hkely  that  the  entire  area  can  not  be  drained  by  one  such  station 
more  may  be  established. 

The  station  consists  of  a  receiving  and  forwarding  section,  a  dress- 
ing and  a  feeding  section.  The  wounded  are  examined,  listed,  sorted 
according  to  their  condition,  and  tagged  if  necessary,  and  fed ;  some 
dressings  may  need  renewal  and  some  exhausted  or  hemorrhage  cases 
may  require  rest  or  hospital  treatment.  Of  course  these  will  be 
detamed. 

Those  to  be  sent  to  the  fine  of  communication  will  be  arranged  in 
detachments  of  30  or  40  and  placed  under  charge  of  slightly  wounded 
officers  or  noncommissioned  officers,  who  will  be  given  orders,  where 
possible,  with  a  list  of  men  in  his  charge,  giving  the  route  of  march. 
This  route  should  coincide  with  a  hne  of  evacuation  of  wounded  so 
that  these  detachments  may  be  convoyed  or  supported  by  wheeled 
convoys  of  wounded  in  order  to  give  care  to  the  exhausted. 

The  commanding  officer  of  the  slightly  wounded  detachments 
should  be  directed  to  leave  any  exhausted  cases  under  shelter  on 
the  route  and  notify  the  nearest  sanitary  echelon  of  their  condition 
and  position.  If  the  road  be  long,  arrangements  \vill  have  been 
made  for  rest  and  refreshment  stations,  which  will  be  necessary  for 
both  the  shghtly  wounded  and  the  transport  cases. 

Field  hospital  companies  belong  to  the  divisional  sanitary  train. 

The  field  hospital  companies  are  controlled  by  a  director  of  field 
hospitals  whose  duties  correspond  to  those  of  the  director  of  ambu- 
lance companies  and  the  field  hospitals,  moved,  estabhshed,  and 
closed  by  orders  of  the  Chief  of  Staff  or  chief  surgeon  usually  through 
the  director,  following  the  methods  outUned  for  ambulance  com- 
panies. 


100  MILITARY   SANITATION    AND   SANITARY    SERVICE. 

The  purpose  of  the  field  hospital  is  to  provide  temporary  shelter 
and  care  for  the  seriously  wounded  or  sick  in  camp  and,  during  and 
after  combat,  pending  their  evacuation  to  the  rear.  Their  capacity 
has  been  changed  from  shelter  (tent)  and  bedding  for  108  to  216 
patients,  giving  for  a  division  864  beds  and  they  carry  technical 
equipment  for  many  more  patients  provided  shelter  and  bedding 
material  can  be  secured  from  local  sources. 

The  personnel  consists  of  6  medical  ofTicers,  9  noncommissioned 
ofhcers,  and  58  privates,  cooks,  etc.  Transportation,  15  mounts, 
7  field  wagons. 

The  equipment  of  our  field  hospital  differs  from  that  of  the  Euro- 
pean armies  in  the  fact  that  it  provides  more  tentage  and  bedding 
equipment,  and  medical  and  surgical  equipment.  The  European 
armies  depending  upon  adventitious  shelter,  bedding,  and  household 
equipment  as  a  whole  or  in  part;  and  in  that  part  of  the  functions  of 
the  field  hospital  are  covered  in  the  dressing  station  of  the  sanitary 
company  or  ''ambulance"  and  part  by  the  clearing  or  evacuation 
hospital. 

A  recent  reorganization  of  the  French  service  found  necessary 
during  the  present  war  has  recognized  the  necessity  of  this  organi- 
zation, which  they  only  had  as  did  the  EngHsh  in  the  shelter  section 
of  the  "field  ambulance"  by  introducing  a  new  miit — the  sm-gical 
operating  hospital,  a  motor  transport  affair  of  100-bed  capacit}^,  with 
a  special  motor  operating  room.  One  of  these  to  an  army  corps. 
The  functions  of  this  organization  are  covered  by  the  equipment  of 
our  field  hospitals.  Although  present  practice  and  opinion  in 
America  and  abroad  questions  the  advisability  of  performing  any 
but  the  most  immediate  necessary  operations,  at  a  point  in  front  of 
the  more  or  less  fixed  hospitals;  because  not  only  must  there  be  little 
or  no  pressure  of  wounded  when  these  are  done,  but  also  cases  of 
this  character  require  post  operative  rest,  which  can  not  be  secured 
in  a  mobile  unit. 

The  field  hospital,  packed,  is  as  mobile  as  its  method  of  transpor- 
tation, field  wagons,  permits.  Motor  trucks,  under  favorable  con- 
ditions, would  materially  increase  this  mobility  and  decrease  road 
distance,  but  such  transport  while  found  satisfactory  abroad  in  th(> 
present  war,  is  of  doubtful  or  impossible  utihty  in  America,  with 
oiu"  poor  roads  and  bridges — such  was  the  opinion  formed,  as  a 
result  of  observation,  in  the  Connecticut  maneuvers  of  1912. 

Not  counting  the  desperately  wounded  who  can  not  endure  extended 
transportation,  and  will  consequently,  not  be  taken  to  the  field  hos- 
pitals, unless  they  establish  on  the  field,  the  field  hospitals  may  bo 
expected  to  care  for  about  60  per  cent  of  the  total  casualties,  a  high 
percentage  of  which  must  be  be(hhHl  until  evacuation.  The  bedding 
capacity  of  the  field  hospitals  as  given  above  is  864  patients  and 


I 


SANITAIiV    SERVICE   IN    COMBAT.  101 

capable  of  extension,  depending  on  local  improvised  shelter  and 
bedding,  straw  with  persoi\al  blankets  collected  on  the  field. 

For  an  Infantry  division  this  will  givo  a  capacity  to  accommodate 
a  total  casualty  of  roughly  10  per  cent.  The  average  daily  battle 
casualties  as  shown  in  the  Franco-Prussian  War  was  for  the  Germans 
4.7  per  cent  and  in  the  Manchurian  for  the  Russians  1.7  per  cent  and 
the  Japanese  2  per  cent.  The  high  losses  shown  in  some  battles  in 
Manchuria  of  as  high  as  68  per  cent  for  some  organizations  were  dis- 
tributed over  several  days,  although  one  division  lost  30  per  cent  in 
a.  single  day.  No  sanitary  service  can  be  equipped  to  handle  such  a 
higli  daily  loss  and,  in  view  of  the  average  losses  given  and  possi- 
bility of  reinforcement  by  organizations  from  divisions  less  hardly 
pressed,  this  capacity  of  10  per  cent  carries  a  fairly  high  factor  of 
safety. 

In  combat,  field  hospitals  will  establish  at  positions  and  times 
selected  by  the  division  commander,  or  surgeon,  in  the  absence  of 
instructions.  In  an  attack  they  will  not  be  established  until  the 
advance  has  ceased  or  the  numbers  of  wounded  at  the  dressmg  sta^ 
tions  justify  such  action.  In  a  planned  defense  they  may  be  estab- 
lished or  at  least  in  position  of  readmess  early,  to  establish  when 
required.  In  a  meeting  engagement,  the  field  hospitals  will  be  halted 
off  the  road  until  the  course  of  action  is  determined. 

In  preparation  for  combat  the  field  hospitals  will  be  assembled  and, 
when  establishment  is  justified,  one  or  more  will  be  sent  forward  to 
cover  the  lines  of  evacuation  from  the  various  sectors;  those  remaiu- 
iQg  unestablished  to  be  held  in  reserve  and  fed  in  either  position,  as 
a  reuiforcement  of  other  hospitals  or  mdependently. 

The  field  hospital  can  be  established  in  about  one  hour,  and  if 
clear,  packed  m  one  and  one-half  hours;  and,  filled  with  wounded, 
vvill  require  three  ambulance  companies  for  its  evacuation  and  a 
much  longer  time  to  dispose  of  the  wounded  and  pack.  Particular 
caro  must  be  taken  to  avoid  establishment  too  early  or  in  an  unsuit- 
able position,  because  for  use  for  the  day  after  establishment,  it  is 
practically  immobile. 

The  site  of  establishment  should  be  some  three  or  five  miles  to  the 
rear;  protected  as  much  as  possible  from  dhected  artillery  fhe;  on 
good  roads,  to  the  front  and  rear;  and  near  the  probable  route  of 
sanitary  evacuation,  which  will  place  it  away  from  the  route  to  the 
front  carrying  ammunition  and  reinforcements.  An  ample  supply  of 
good  water  is  necessary,  and  it  should  be  located,  where  possible,  near 
suitable  buildmgs;  these  can  be  utilized  as  shelter  in  place  of  or  in 
addition  to  the  tentage  carried;  in  addition  to  shelter,  the  vicinity 
should  also  afford  household  conveniences,  straw  and  wood.  In 
selecting  a  location  for  a  field  hospital,  while  due  regard  should  be 
given  to  the  proximity  of  permam^nt  objects,  as  a  means  of  locating 


102  MILITARY    SANITATION    AND    SANITARY    SERVICE. 

it;  nevertheless  the  buildings,  or  site  occupied  by  it,  should  not  be 
capable  of  being  seen  from  the  front,  owing  to  the  tendency  of  hostile 
Artillery  to  fire  on  aggregations  of  buildings,  men,  or  troops.  Expe- 
rience in  the  pan-European  War  would  lead  to  the  assumption  that 
the  Red  Cross  flag  is  not  easily  recognized,  as  such,  at  distances  given, 
or  that  its  protection  has  been  disregarded.  When  establishmg  with 
adventitious  shelter  much  of  the  heavy  equipment  of  the  field  hos- 
pitals will  not  be  unpacked,  and  the  personnel  will  be  employed  in 
collecting  and  improvising  local  equipment  and  materials  for  hospital 
uso. 

The  various  routes  to  the  field  hospitals  will  be  marked  by  day 
and  night,  by  guidons,  signs,  or  lanterns.  The  same  care  here  is 
not  necessary,  as  in  the  dressing  stations  to  avoid  attracting  hostile 
attention,  by  guide  flags,  as  the  distance  is  too  great  to  permit 
recognition  of  ordmary  sized  flags. 

Given  other  conditions  as  satisfactory,  the  field  hospitals  will  be 
located  so  as  to  cover  the  field  of  greatest  casualty,  and,  should  the 
enemy  retire,  they  will  be  located  near  the  dressing  stations  or  on 
the  field  itself.  Where  field  hospitals  are  ordered  up  to  replace  a 
dressing  station,  they  will  transfer  the  equipment,  by  exchange,  and 
take  over  the  wounded,  releasing  this  part  of  the  ambulance  com- 
pany for  further  duty  elsewhere. 

The  positions  of  the  field  hospitals  on  the  march  with  a  division, 
when  hostile  contact  is  expected,  lend  ease  to  their  establishment,  or 
position  in  readiness,  following  deployment  of  the  division.  Their 
position  at  the  rear  of  the  main  body  places  them  some  five  miles  to 
the  rear  of  the  head  of  the  main  body,  and  should  this  deploy  on  a 
position  taken  up  by  the  advance  guard  movement  forward  at  ordi- 
nary gaits,  could  put  the  field  hospitals  near  their  probable  position 
within  an  hour  and  a  half  after  the  order  for  deployment  is  given, 
rather  too  early  for  a  position  in  readiness. 

In  order  to  clear  the  road,  however,  and  put  them  near  where  will 
be  their  probable  location,  plans  of  the  division  commander,  roads 
and  terrain,  and  probable  field  of  casualties  and  fire  considered,  the 
field  hospitals  will  be  moved  foi-ward,  or  assembled  at  a  convenient 
point  on  a  probable  route  of  evacuation. 

The  director  will  inform  himself  of  conditions  of  shelter,  suppl}'^, 
and  communication  in  the  rear  of  the  sector  covered  by  the  division, 
and,  as  soon  as  he  receives  information  as  to  the  sites  of  the  field 
hospitals,  will  designate  the  organizations  and  arrange  for  use  of 
shelter  and  supplies  at  hand.  He  will  get  in  touch  with  the  director 
of  ambulance  companies  and  arrange  for  coordmating  his  service  with 
that  of  the  trajisport.  The  <livision  surgeon  will  be  notified  of  the 
time  of  establishment  as  it  occurs. 


SANITARY   SERVICE   IN    COMBAT.  103 

The  field  hospital  will  establish :  A  receiving  and  forwarding,  slightly 
wounded  (sitting),  a  seriously  wounded  (bed),  an  operating,  dispen- 
sary, kitchen,  morgue,  and  transportation  department. 

The  receiving  and  forwarding  section  will  record,  sort,  and  assign 
patients  on  receipt  and  dispatch  through  the  transport  section,  mov- 
mg  the  received  patients  to  the  wards  and  operating  section,  accord- 
ing to  their  classification,  or  turn  them  over  to  the  transport  column 
for  evacuation.  The  operating  section  will,  as  stated  before,  avoid 
operations,  which  can  be  delayed  until  more  suitable  environments 
are  available,  and  confine  itself  to  those  immediately  necessary  to 
save  life,  or  to  prepare  patient  for  evacuation.  Patients  will  be 
cleared  from  the  field  hospitals  established,  ordinarily,  by  transfer  to 
line  of  commimications  columns,  transporting  them  to  evacuation 
hospitals  on  trains  or  water  transportation  or,  in  default  of  these  lines 
of  communications,  to  other  field  hospitals  at  the  rear,  in  order  to 
permit  release  of  mobile  units  to  join  their  command.  Transfer  of  the 
disabled  is  most  easily  and  satisfactorily  made  by  bringing  up  evacua- 
tion hospital  personnel  and  equipment  on  wagons  or  motors  and 
exchanging  equipment. 

Under  conditions  where  it  will  be  impossible  to  evacuate  all  of 
the  wounded  in  a  field  hospital  (as  where  one  is  detailed  to  care  for 
desperately  wounded,  in  an  advance  or  immobdized  with  wounded  in 
a  retreat),  these  wounded  may  be  left  with  suitable  personnel  and 
equipment  and  the  remainder  move  out  with  the  train. 

The  personnel  of  the  field  hospital  company  will  ordinarily  furnish 
the  personnel  for  the  station  for  shghtly  wounded,  and  this  will  usu- 
ally be  designated  by  the  director  from  that  of  a  field  hospital  which 
will  be  placed  nearest  this  organization,  in  order  to  avoid  unnec- 
sary  movement  of  transportation  and  personnel  in  estabhshing  and 
closing.  Prior  to  the  time  when  field  hospitals  estabhsh  or  in  delay- 
ing engagements,  when  estabhshment  would  be  inadvisable,  the  per- 
sonnel of  the  field  hospital  companies  may  be  used  to  advantage  as 
bearer  detachments  and  reinforcements  to  the  dressing  station  per- 
sonnel. 

The  entire  sanitary  service  of  the  division  must  be  under  the  ob- 
servation and  control  of  the  division  surgeon,  either  through  the 
chief  of  staff,  or  direct.  The  service  of  the  regimental  sanitary  troops 
will  be  largely  independent,  under  the  control  of  the  regimental 
commander  and  sm'geon,  as  to  estabhshment,  disestabhshment,  and 
interior  administration,  but,  under  the  regulations  a  surgeon  may 
be  detached  for  duty  at  a  dressing  station  and  field  hospitals,  and 
this  will  be  done  by  the  chief  sm^geon,  when  necessary,  from  those 
organizations  least  engaged  with  casualties. 

The  surgeon  will  require  reports  of  the  time  and  site  of  estabhsh- 
ment and  disestabhshment,  the  number  of  casualties,  etc.,  in  order 


104  MILITARY    SANITATION    AND    SANITARY    SERVICE, 

that  he  may  be  able  to  direct  the  sanitary  service  economically  and 
use  the  regimental  and  divisional  sanitary  personnel  in  the  best 
manner,  in  the  service  of  dressing  and  evacuation. 

While  the  station  of  the  division  siu-geon  is  with  the  headquarters 
of  the  division,  he  must  exercise  general  supervision  over  the  entire 
field,  either  by  use  of  his  assistant  and  the  sanitary  inspector,  or  by 
leaving  one  of  these  in  charge  of  his  office,  by  direct  examination  of 
the  conditions.  The  duties  of  the  surgeon  lie  in  administration  and 
direction,  and  he  can  best  serve  the*  sanitary  service  by  exercising 
these  fiuictions,  rather  than  by  personal  care  of  the  wounded.  He 
will  coordinate  the  work  of  the  several  fines  of  sanitary  aid,  in  order 
to  procure  rapidity  and  continuity  of  action,  in  care  and  evacuation 
of  the  disabled;  and,  guided  by  his  information  of  the  plan  and  course 
of  the  combat,  direct  the  movement,  establishment,  and  closure,  of 
the  organizations  within  his  department. 

Orders  for  this  purpose  will  be  issued  by  the  chief  of  staff  upon 
recommendation  of  the  division  surgeon  or  may  be  direct  by  the 
surgeon,  when  so  authorized  l^y  the  division  commander.  It  would 
seem  that  in  stress  of  a  general  action  it  would  be  necessary  for 
orders  to  be  issued  frequently,  direct  by  the  surgeon  to  the  du-ector 
of  ambulance  companies  and  field  hospitals  in  order  to  avoid 
damaging  delays,  and  it  is  probable  that  the  division  commander 
will  issue  general  authority  to  cover  such  action.  Orders  to 
directors  and  unit  commanders  shoidd  be  so  worded,  as  to  cover 
the  general  requirements,  leaving,  as  in  orders  for  combatant  com- 
manders, arrangement  of  details  to  the  officer  of  whom  the  action  is 
expected. 

Orders  directing  estabfishing  or  requiring  movement  to  a  position 
in  readiness  should  carry  the  phrase  "in  the  vicinity  of"  or  "near  a 
certain  point,"  in  order  to  permit  use  of  natural  or  artificial  features 
of  terrain,  shelter,  cover,  or  supply.  Orders  to  directors  should  be 
sufficiently  broad  to  permit  adaptation  of  the  units  on  hand  to  the 
particular  requirements. 

Communication  and  interchange  of  information  will  be  constantly 
kept  up  between  the  sanitary  service  of  the  zone  of  advance  and  the 
fine  of  communication  in  order  that  the  service  of  the  medical  sui)ply 
and  evacuation  may  be  most  efficient.  Arrangement  will  be  made 
for  movement  of  supplies  to  the  railhead  or  distributing  point  and 
transportation  to  organization  for  reequipment  after  combat.  The 
advance  surgeon  will  be  notified  of  the  location  of  field  hospitals  and 
the  distribution  and  classification  of  wounded  or  sick  therein,  together 
with  conditions  of  roads,  etc.,  in  order  that  they  may  be  taken  over. 
On  the  march  and  in  camps  preparatory  to  evacuation,  rendezvous 
points  for  collection  of  disabled  wiU  be  arranged  for  between  the  divi- 
sion and  advance  surgeons,  and  the  sanitary  service  line  of  communi- 
cations Mill  l)e  kept  informed  as  to  possibility  of  combat,  change  of 


SAN1TAI;^     SKUVICE    IN    COMBAT.  105 

route,  presenco  of  epidemics,  etc.,  in  order  that  preparation  can  be 
made  in  advance  for  unusual  conditions. 

The  police  of  the  battlefiekls,  as  stated  before,  will  be  attended  to 
by  the  local  commander  in  liis  sector.  Usually  the  sanitary  inspector 
will  be  detailed  to  supervise  the  sanitation  of  the  field  and  wiU  be 
given  such  saaitary  and  combatant  assistance  by  local  commanders, 
under  ordei-s  from  the  division  commander,  as  may  be  necessary. 
Sites  for  interment  or  cremation  of  men  and  animals  will  be  chosen 
by  the  sanitary  inspector  with  due  regard  to  character  of  soil,  drainage, 
convenience  to  field,  and  unlikeUhood  of  disturbance  by  flood  or 
animals.  Action  will  be  taken  to  procure  medical  officers  and  chap- 
lains from  the  troops  of  each  locahty  for  examination  and  record  of 
the  dead  and  for  appropriate  services;  and  details  of  a  noncommis- 
sioned officer  or  private  from  each  company  to  assist  in  recognition, 
in  cases  where  the  identification  tag  is  not  found ;  and  burial  details 
for  collection  and  transporting  the  dead  and  preparing  and  conduct- 
ino-  the  work  of  interment  or  cremation.  All  dead  will  be  recorded 
on  casualty  fists,  with  organization  and  cause  of  death,  and  separate 
trenches  prepared  for  the  unknown  and  the  known  of  our  own  troops, 
and  for  the  enemy's.  Those  of  the  same  organization  wiU,  as  m^uch 
as  possible,  be  buried  together,  and  those  of  our  own  troops  will  have 
their  tags  buried  with  them,  secured  to  the  neck  by  a  copper  wire  of 
generous  size.  The  tags  of  the  enemy  or  of  the  cremated  dead  will  be 
retained.  Careful  note  of  location  and  contents  of  burial  trenches 
will  be  made  to  facifitate  later  removal  and  recogrution.  Trenches 
will  be  made  at  least  5  feet  deep — that  is,  bodies  should  be  covered 
by  4  feet  of  earth — in  order  to  prevent  escape  of  gases  of  decomposi- 
tion or  exhumation  by  flood  or  animals. 

All  spare  earth  should  be  used  in  mounding  trenches,  in  order  to 
provide  for  sinking  and  to  give  additional  covering.  As  a  matter  of 
sentiment  and  comfort  to  relatives,  it  is  well  to  have  chaplains  of 
several  denominations  hold  services  for  the  dead,  so  that  each  may 
have  the  benefit  of  the  particular  rites  of  Ins  church. 

Given  proper  space  and  soU,  burial,  if  properly  conducted,  is  not 
objectionable.  Ordinarily,  in  disposition  of  the  dead,  the  end  to  be 
secured  is  destruction  of  the  putrescible  parts  of  the  body,  in  the  least 
time,  without  real  or  sentimental  offense.  To  secure  the  most  rapid 
decomposition,  all  clothing,  covering,  or  boxing  of  bodies  should  be 
interdicted  and  the  mass  of  dead  should  be  supported  upon  a  course 
of  open  stone  or  logs  in  the  bottom  of  the  trench,  with  a  drain  for 
fluids  leading  to  a  lower  pit.  The  mass  should  be  topped  with  a 
layer  of  straw  or  branches,  in  order  to  prevent  too  close  contact  of  the 
earth,  which  will  prevent  drainage  and  rapid  disintegration,  and 
lastly  mounding  with  all  earth  removed.  The  use  of  fime  or  of  other 
disinfectants  on  the  bodies,  or  in  the  grave,  prevents  rapid  disinte- 


106  MILITARY    SANITATION    AND   SANITARY    SERVICE. 

gration  and  defeats  the  purpose  of  interment,  without  accomplishing 
anything  that  can  not  he  done  by  four  feet  of  earth.  Properly 
located  and  drained  trenches  will  secure  this  and  be  relatively  safe. 

Cremation  is  usually  impracticable  on  account  of  difficulty  of  pro- 
curing fuel  in  sufficient  quantities,  as  one  single  body  on  an  open  pyre 
will  require  one-third  of  a  cord  of  wood  and  at  least  five  hours  of  at- 
tention. While  this  is  an  ideal  method  of  disposition  of  the  dead, 
pubhc  sentiment  is  as  yet  hardly  sufficiently  educated  to  make  it 
justifiable,  when  interment  is  practicable;  but  where  fuel  is  at  hand 
and  character  of  soil  or  rock  formations  and  lack  of  space,  as  within 
a  beleaguered  area,  does  not  permit  interment,  it  is  demanded. 

The  records  of  the  friendly  dead  will  be  data  for  casualty  reports. 
The  tags,  records,  private  papers,  and  possessions  of  the  hostile  dead 
will  be  turned  over  to  the  provost  marshal,  who  will  send  them  to 
the  War  Department  for  ultimate  transmittal  to  relatives,  or  other 
parties  in  interest,  in  the  home  country. 

SERVICE  OF  THE  LINES  OF  COMMUNICATIONS,  BEFORE,  DURING,  AND 

AFTER  COMBAT. 

As  stated  in  former  lectures  the  sanitary  service  of  the  lines  of 
communications  is  divided  according  to  the  general  organization, 
into  advance,  intermediate,  and  base  groups ;  each  with  their  proper 
surgeon  and  equipment  of  personnel,  units,  and  supply — with  the 
advance  and  intermediate  groups  subordinate  to  the  commander  at 
the  base. 

The  functions  of  the  surgeon  of  the  base  group  are  practically  those 
of  a  division  surgeon,  and  he  is  governed  by  similar  regulations.  He 
will  have  charge  of  the  direction  of  the  transportation,  care,  and  distri- 
bution of  patients  from  the  time  that  they  are  turned  over  to  the  lines 
of  communications  until  their  final  disposition,  either  by  transfer  to 
the  service  of  the  interior  or  return  to  their  organizations,  and  for 
the  purpose  of  caring  for  them  he  will  utihze  all  means  of  transporta- 
tion, hospitals,  and  convalescent  camps  within  liis  control  and,  imder 
authority  of  the  commanding  officer,  lines  of  communications,  will 
create  or  estabfish  such  other  organizations  as  may  be  necessary.  He 
will  arrange  for  the  supply  of  sanitary  personnel  for  the  lines  of  com- 
munications and  to  the  sanitary  troops  of  the  zone  of  advance,  and 
in  order  to  regulate  the  flow  of  these  personnel  to  the  front  will 
estabfish  casual  camps  for  these  troops;  will  establish  and  control 
depots  for  sanitary  suppfies,  which  will  be  issued  to  the  organizations 
on  the  fines  of  communications  and  the  zone  of  the  advance;  and 
will  exercise  sanitary  supervision  and  control  over  the  area  of  the 
lines  of  communication  and  the  country  contiguous  thereto. 

Previous  to  combat  the  surgeon,  base  group,  will  bo  informed  as  to 
the  probability  of  action  and  will  direct  his  subordinates  to  prepare 
all  of    their  organization  for  additional  service.     All  lu)spitals  and 


SANITARY   SERVICE   IN    COMBAT.  107 

institutions  will  bo  rosiij)pli(Hl  aiul  cleared  of  patients,  and  mobile 
and  semimobile  units  collected  at  convenient  points  in  tlio  advance 
or  intennediate  groups  for  service.  Advance  depots  will  be  supplied 
and  additional  units  organized  as  required. 

.  On  notification  of  imminence  of  action  the  surgeon  advance  groups 
will  bring  his  evacuation  hospitals  up  to  the  railheads,  and  if  the 
probable  seat  of  action  is  well  removed  from  water  or  railheads,  wiU 
provide  motor  or  wagon  transport  for  them,  so  that  they  can  be 
advanced  as  necessary.  Hospital  trains  or  boats  will  be  brought  up 
to  the  transportation  head  and  sections  of  advance  supply  depots 
equipped  with  transportation  for  movement  to  the  distributing  point. 
The  evacuation  ambulance  company  will  be  reinforced  by  additional 
wagon  or  motor  transport  and  advance  well  toward  the  tail  of  the 
column  in  the  zone  of  the  advance.  Sites  and  shelter  for  hospitals 
and  convalescent  camps  will  be  selected  and  plans  and  equipment 
for  improvisation  of  trains  and  boats  for  patients  prepared,  in  accord- 
ance with  local  conditions.  Details  for  embarkation  stations  will  be 
brought  up  and  rest  stations,  personnel,  and  equipment  reinforced; 
and  all  measures  possible  taken  to  secure  rapid  and  efficient  evacua- 
tion, care,  and   distribution  of  the  disabled. 

The  evacuation  ambulance  companies  of  the  lines  of  communica- 
tions are  allowed  normally  on  the  basis  of  one  to  each  division,  and 
carry  the  same  personnel  and  equipment  and  transportation  as  do  the 
ambulance  companies,  less  the  four  pack  mules.  They  will  be  used 
for  road  evacuation  of  the  disabled  from  the  field  hospitals  to  the 
evacuation  hospitals  or  rail  or  water  head.  Under  normal  con- 
ditions of  daily  flow  of  disabled  and  .usual  road  distance,  their  capacity 
is  ample,  but  in  preparation  for  combat  they  must  be  largely  increased 
as  to  transportation  and  personnel  by  attachment  of  enlisted  men  and 
wheeled  vehicles  with  enhsted  or  civihan  drivers. 

These  organizations  under  usual  conditions  of  weather,  work,  on 
more  or  less  satisfactory  roads,  can  employ  motor  transportation  with 
excellent  results.  On  the  continent,  where  the  roads  are  admittedly 
better  than  in  America,  transport  colmnns  are  composed  entirely  of 
motor  ambulances,  organized  in  groups  of  50,  divided  into  three 
sections.  The  use  of  such  means  of  transport  has  made  possible  the 
rapid  evacuation  of  the  enormous  number  of  wounded,  which  would 
otherwise  have  encumbered  the  mobile  organizations  for  days.  To 
man  this  additional  transportation,  the  bearer  detachment  is  available 
either  as  attendants  or  chivers.  Automobile  transportation  in  tliis 
organization  is  more  economical  in  persomiel,  as  the  chauffeurs  them- 
selves can  be  used  as  a  loading  detail  and  attendants,  as  they  have  no 
teams  that  require  watchmg  when  halted.  The  transport  column, 
when  route  conditions  require  extensive  marches,  will  establish  rest 
stations  en  route  for  the  care,  feeding,  and  treatment  of  the  wounded 


108  MILITARY    SANlTAnON    AND    SANITARY    SERVICE. 

en  route,  detaching  a  medical  officer  or  a  detail  of  enlisted  men  and 
equipment  for  this  purpose. 

The  rest  stations  of  a  line  of  evacuation  is  on  a  byroad,  and  will  be 
established  at  points  at  march  intervals  or  less  and  will  be  an-anged 
by  use  of  buildings  or  other  shelter  for  feeding  and  dressing  ordinary 
cases  in  transport  and  bed  equipment  for  those  cases  that  become 
imtransportable.  Arrangement  must  be  made  for.  rapid  feeding  at 
these  points,  and  measures  will  ordinarily  be  taken  to  apprise  the 
stations  of  the  time  of  arrival  of  convoys  of  womided.  Should  the 
route  of  evacuation  be  relatively  extended  and  permanent,  special 
parties  will  be  sent  up  from  the  sanitary  reserve  of  the  line  of  commu- 
nications to  relieve  the  evacuation  ambulance  company  persoimel 
and  equipment. 

Transport  colimins  and  rest  station  parties  of  volunteer  aid  societies 
are  extensively  used  abroad  for  this  duty,  and  can  be  weU  used  in 
oiu"  service  particidarly  as  a  second  echelon  on  long  routes  of  evacua- 
tion .  Where  convenient,  those  colimms  and  rest  stations  in  the  ad- 
vance section  should  consist  of  the  military  sanitary  service. 

Embarkation  stations  are  formed  at  the  transport  head,  particu- 
larly^ at  rail  and  water  heads,  for  the  reception,  care,  and  loading  of 
the  disabled;  delivered  by  transport  units,  pending  arrival  of  other 
means  of  transportation :  these  correspond  in  organization  and  equip- 
ment to  rest  stations,  but  must  have  greater  bed,  feeding,  and  shelter 
facilities.  They  may  be  formed  of  line  of  connnimications  reserves 
or  from  aid  societies  personnel,  with  a  military  control.  As  ihcj  are 
relatively  stationary  and  wiU  have  advantage  of  good  shelter  and 
accommodations  near  a  fixed  line  of  transportation,  they  can  be 
manned  by  voluntary  aid  personnel  to  advantage.  Their  fimctions 
and  duties  are  obvious. 

Rest  stations  on  railway  and  water  transport  lines  wiU  ordinarily 
not  be  required  by  hospital  trains,  as  they  will  be  equipped  with 
ordmary  necessities  for  feeding  and  caring  lor  the  sick.  Trains  and 
boats  for  patients,  however,  wiU  not  be  provided  with  facilities  for 
feeding  the  disabled;  rest  stations  must  be  equipped  with  material 
and  personnel  for  this  purpose.  They  will  be  located  on  a  siding  or 
dock,  where  boats  or  trains  can  be  stopped  conveniently,  and  will 
have  meals  prepared  in  advance,  through  proper  notification.  In 
order  to  expedite  movement,  action  can  be  taken,  as  in  the  Gorman 
service,  to  load  prepared  meals  and  serving  equipment  on  trains  at 
the  rest  stations.  The  serving  equipment  to  be  brought  back  on  the 
next  trip. 

More  elaborate  dressing  and  ward  equipment  will  be  provided  at 
these  points  than  is  had  at  the  road  stations.  The  pei*sonncl  should 
consist  of  2  medical  officers,  and  some  15  or  20  cooks  or  attendants, 
arranged  in  day  and  night  shifts. 


SANITARY    SERVICE   IN    COMBAT.  109 

The  evacuation  hospitals  are  allowed  2  to  a  division;  pcrsoini el, 
14  medical  officers  and  129  enlisted  men;  equipment  of  2  field 
hospitals  and  divisible  into  sections.  Evacuation  hospitals  have 
no  transportation  fixed,  but  will  requrre  some  16  wagons.  Held 
well  up  on  the  lines  of  conimimications,  they  will  be  available  for  use 
at  the  front  as  soon  as  the  conditions  of  the  combat  are  detenniiied. 
Their  f miction  is  to  provide  more  elaborate  care  for  the  woimded 
than  can  be  given  in  the  field  hospitals,  and  they  will  be  used  primarily 
to  clear  the  field  hospitals,  so  that  they  can  move  forward  with  the 
command.  As  they  have  no  transportation,  they  will,  ordinarily, 
be  kept  on  a  water  or  rail  transport  line,  packed  for  rapid  movement. 

In  or  after  combat,  these  organizations  may  be  established  in 
whole  or  part,  or  by  section  at  the  lines  of  comnumication  transport 
head,  or  near  the  field,  or  moved  to  the  field  and  take  over  the 
womided  and  field  hospitals,  by  exchange  of  equipment.  In  the 
movement  to  the  field,  if  no  other  transportation  is  available,  the 
evacuation  ambulance  company  may  be  used  as  transportation. 

The  equipment  of  the  evacuation  hospitals  permits  use  of  tentage 
for  shelter,  but  wherever  possible,  buildings  of  the  locality  wiU  be 
taken.  Here,  more  elaborate  surgery  can  be  done,  as  these  hospitals 
may  be  fixed,  if  necessary,  and  reserve  organizations  sent  up  from 
the  base  of  the  general  line  of  commmiications.  Here,  the  definite 
sorting  of  patients  will  be  made,  and  distribution  according  to 
probable  length  of  disability  be  accomplished.  The  lightly  womided, 
sent  to  the  convalescent  camps,  advance  groups;  those  of  moderate 
severity  to  the  hospitals  of  the  intermediate  and  base  groups,  in- 
fectious cases  diverted  to  special  hospitals,  and  the  relatively  per- 
manently disabled  sent  to  the  base,  en  route  to  the  service  of  the 
Ulterior. 

o 


14  DAY  USE 

RETURN  TO  DESK  FROM  WHICH  BORROWED 

BIOLOGY  LIBRARY 

TEL.  NO.  642-2531 

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